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mtteCitpofi^etDgorfe 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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Given  by 


Annex 


THE    DISEASES 
OF   THE    STOMACH 


BY 

Dr.  C  a.   EWALD 

EXTRAORDINARY    PROFESSOR    OF    MEDICINE    AT    THE    UNIVERSITY    Cr    BERLIN 
DIRECTOR    OF    THE    AUGUSTA    HOSPITAL,    ETC. 


TRANSLATED  AND  EDITED,    IVITH  NUMEROUS  ADDITIONS, 
FROM   THE   THIRD   GERMAN  EDITION 

By   morris   manges,    A.M.,    M.  D. 

ASSISTANT    VISITING    PHYSICIAN    TO    MOUNT    SINAI    HOSPITAL 
LECTURER    ON    GENERAL    MEDICINE    AT    THE    NEW    YORK    POLYCLINIC,    ETC. 


SECOND    REVISED    EDITION 


NEW    YORK 
D.    APPLETON    AND    COMPANY 

1900 


Copyright,  1892,  1897, 
By  D.  APPLETON  A::yD   COMPACT. 


PEEFACE   TO   THE   SECOND   AMERICAN 
EDITION. 


The  great  progress  wliich.  lias  been  made  in  our  knowledge  of 
the  diseases  of  the  stomach  since  the  appearance  of  the  first  edition 
of  this  work  in  1892  has  rendered  a  new  edition  necessary.  This  is 
based  upon  the  last  (third)  German  edition,  which  was  published  in 
1893,  which,  as  may  be  learned  from  Prof.  Ewald's  preface,  was  a 
complete  revision  of  the  earlier  work.  With  few  exceptions  I 
have  followed  the  author's  text  and  have  everywhere  presented  his 
views,  even  where  subsequent  mvestigations  have  since  modified 
them.  The  current  opinions  have  been  appended,  attention  being 
at  the  same  time  called  to  the  change.  In  addition,  much  new 
matter  has  been  incorporated  into  the  text  and  footnotes.  Al- 
though I  have  endeavored  to  render  the  revision  as  complete  as 
possible,  it  is  probable  that  I  have  failed  to  include  everji:hing 
which  was  worthy  of  notice.  The  literature  on  the  diseases  of  the 
stomach  is  now  so  extensive  that  to  have  included  everything  would 
have  been  mipossible. 

New  illustrations  have  been  added,  so  that  the  present  edition 
contains  thirteen  figures  which  are  not  in  the  German  edition.  A 
number  of  the  other  figures  has  also  been  redrawn. 

All  the  new  matter   and   illustrations   have   been   inclosed   in 

[     ]• 

An  esteemed  reviewer  of  the  first  edition  has  taken  exception 
to  the  naming  of  special  manufactures  of  drugs  and  food  products. 
Although  I  agree  entirely  with  him  on  this  point,  yet  this  was  un- 
avoidable ;  for  it  had  only  been  done  wherever  Prof.  Ewald  has 
recommended  specific  preparations  which  were  unknown  to  the 


IT 


DISEASES  OF   THE   STOMACH. 


majoritj  of  American  practitioners.  I  liave  referred  to  this  detail 
because  tlie  same  custom  lias  also  been  followed  in  the  present 
edition. 

I  am  indebted  to  Dr.  Albert  Kohn  for  assistance  in  the  prepara- 
tion of  the  index. 

M.  Madges. 

941  Madison  Avenue,  New  York,  Aug.  1,  1S96, 


PREFACE   TO   THE  THIRD   GERMAN  EDITION, 


The  very  favorable  reception  which,  has  everywhere  been 
accorded  to  this  book  *  has  spurred  me  on  to  special  exertions  in 
writing  the  present  edition.  I  have  therefore  not  only  added  con- 
siderable new  matter,  but  have  also  entirely  rewritten  the  work. 
This  was  necessary,  because,  on  the  one  hand,  the  clarifying  process 
which  has  been  going  on  in  this  branch  during  the  past  years  has 
enabled  us  to  throw  aside  much  superfluous  matter,  and,  on  the 
other  hand,  many  new  facts  and  observations  have  accumulated. 

The  arrangement  of  the  chapters  has  been  somewhat  changed, 
so  as  to  correspond  more  closely  to  the  development  and  relation  of 
the  various  diseases. 

I  have  not  refrained  from  adding  many  new  personal  obser- 
vations and  therapeutic  experiences,  which  I  trust  may  be  found 
useful,  although  they  are  thus  lost  to  the  current  literature,  which 
represents  only  journal  articles  or  abstracts  of  them. 

So  far  as  concerns  the  general  pathological  views  on  which  the 
book  is  based,  there  has  been  little  which  has  required  alteration. 
Taken  all  in  all,  my  original  views  have  been  substantiated  by  the 
work  which  has  been  done  on  gastric  disorders  during  the  past  ten 
years.  It  has  been  demonstrated  that,  after  all,  in  spite  of  the  stom- 
ach tube,  miracles  can  not  be  performed,  and  that  the  physician's 
general  knowledge,  perspicacity,  and  judgment  are  still  of  primary 
importance  ! 

I  would  also  direct  attention  to  the  progress  made  during  the 
past  few  years  in  gastric  surgery,  which  has  now  passed  beyond  the 

*  Within  a  short  period  three  editions  have  appeared  and  translations  pub- 
lished in  England  (Xew  Sydenham  Society),  Spain,  France,  Italy,  and  the  United 
States, 

T 


vi  DISEASES  OP  THE  STOMACH. 

stage  of  a  few  isolated  daring  operations.  In  the  discussion  of  the 
various  diseases  I  have  considered  the  indications  for  operative 
interference,  and  have  presented  the  pros  and  cons  so  far  as  would 
be  necessary  to  enable  a  physician  to  determine  whether  in  a  concrete 
case  the  aid  of  the  surgeon  might  be  required.  The  latter  may  then 
consider  the  indications  from  the  surgical  standpoint.  To  present 
these  details,  or  to  give  the  technique  of  the  various  operative  pro- 
cedures, has  been  unnecessary,  for  the  operator,  be  he  a  surgeon  or 
a  general  practitioner  who  is  compelled  to  resort  to  the  knife  only 
occasionally,  will  not  consult  a  work  on  clinical  medicine  for  such 
details. 

The  present  book,  based  upon  lectures  which  were  delivered  be- 
fore practitioners  and  which  were  subsequently  enlarged,  has  been 
designed  for  general  practitioners  and  students  ;  every  part  has  been 
considered  from  this  standpoint  and  represents  an  extensive  practi- 
cal experience.  I  wish  to  contrast  it  with  the  recent  small  manuals 
on  this  subject,  which  are  "  adapted  to  the  needs  of  the  general 
practitioner."  The  thorough  and  earnest  physician  "wishes  to  obtain 
the  current  general  views  on  the  subject,  and  to  get  advice  in  diffi- 
cult cases.  I  trust  that  their  needs  will  be  fulfilled  in  the  same 
increasing  degree  as  the  personal  experience  of  the  author  has 
grown,  and  that,  in  spite  of  its  revision,  the  book  has  not  lost  its 
original  freshness. 

C.  A.  EWALD. 

Berlin,  April  15, 1893. 


CONTENTS. 


Preface  to  the  second  American  edition iii 

Preface  to  the  third  German  edition v 

CHAPTER  PAGE 

I. — Methods    op   examination, — Determination   of    the    acidity   and 

ACIDS   OF   THE   CONTENTS   OF   THE   STOMACH 1 

II, — Methods  of  examination  {continued). — Determination  of  the  di- 
gestion OF  ALBUMEN  AND  STARCH. — ABSORPTION  AND  MOTILITY. — 
The   TECHNIQUE   OF   THE   EXAMINATION  OF   THE   STOMACH     ,  ,  ,         60 

III, — Stenoses  and  strictures  of  the  oesophagus  and  of  the  cardia   .    109 

IV, — The  general  relations  of  the  stomach  to  the  organism. — In- 
flammation   OF    the    stomach. — Gastritis    glandularis    acuta, 

IDIOPATHICA   ET   SYMPATHICA. — GASTRITIS   PHLEGMONOSA   PURULENTA. 

Gastritis  toxica 155 

v. — Chronic  glandular  gastritis. — Chronic  catarrh  of  the  stomach  .  192' 

VI. — [Mechanical]  insufficiency  and  dilatation  of  the  stomach  ,        .  254 

VII, — Cancer  of  the  stomach 313 

VIII. — Ulcer  of  the  stomach. — Ulcus  pepticum  seu  rodens      .        .        .  377 

IX. — The  neuroses  of  the  stomach. — The   physiological   relations  of 

the  stomach 448 

X, — The  neuroses  of  the  stomach 478 

XI. — The  neuroses  of  the  stomach  {continued) 501 

XII. — The  correlation  of  the  diseases  of  the  stojiach  to  those  of 
other  organs. — The  practical  value  of  the  modern  chemical 
tests 563 

Index 583 


LIST  OF  ILLUSTRATIONS. 


PAGE 

1.  Lower  end  of  Ewald's  stomach  tube 6 

2.  Boas's  aspirator 13 

3.  Curling  over  of  flexible  tube  in  the  stomach 16 

4.  Curve  showing  the  course  of  the  secretion  of  hydrochloric  acid  ...  27 

5.  Curve  showing  the  course  of  the  secretion  of  hydrochloric  acid  as  calcu- 

lated according  to  different  methods 58 

6.  [Microscopical  appearance  of  stomach  contents] 74 

7.  Vertical  position  of  stomach  and  exposure  of  body  of  pancreas  ...  90 

8.  [Cast  of  cylindriform  stomach  in  vertical  position] 91 

9.  [Cast  of  normal  stomach] 91 

10.  [Cast  of  dilated  stomach  in  normal  position] 91 

11.  [Cast  of  markedly  dilated  stomach  tending  to  assume  vertical  position]     .  91 

12.  Contraction  of  stomach  in  a  case  of  cancer  and  stenosis  of  oesophagus       .  94 

13.  [Einhorn's  gastrodiaphane] 96 

14.  Gastrodiaphanic  picture  in  normal  stomach 97 

15.  Gastrodiaphanic  picture  in  dilated  stomach 97 

16.  Gastrodiaphanic  picture  in  gastroptosis        .        .       ■ 97 

17.  Gastrodiaphanic  picture  in  gastroptosis 97 

18.  Stand  for  holding  stomach  tube 99 

19.  [Auto-lavage  of  stomach] 100 

20.  [Hemmeter's  recurrent  stomach  tube] 101 

21.  Deglutable  stomach  electrode 103 

22.  Cicatricial  stenosis  of  oesophagus  in  child     .         .         ...         .         .        .  115 

23.  Localized  cancer  of  cardiac  orifice  of  stomach 122 

24.  Carcinoma  surrounding  cardia,  side  view 130 

25.  Carcinoma  surrounding  cardia,  front  view 131 

26.  Carcinoma  of  oesophagus  just  above  cardia 137 

27.  Section  of  piece  of  mucous  membrane  of  stomach  found  in  wash-water 

during  lavage  of  empty  stomach 196 

28.  Section  of  mucous  membrane  of  atrophic  stomach 198 

29.  Section  of  mucous  membrane  of  stomach  ;  marked  atrophy        .        .        .  201 

30.  Section  of  mucous  membrane  of  stomach  ;  cirrhotic  atrophy      .        .        .  202 

31.  Section  of  mucous  membrane  of  stomach  ;  total  atrophic  sclerosis      .        .  204 

32.  [Turck's  gyromele] 237 

ix 


DISEASES  OF  THE  STOMACH. 


33.  [Tumor   caused  by  dilated  stomach,  front  view,  showing  increased 

stalsis] 

34.  [Tumor  caused  by  dilated  stomach,  side  view] 

35.  [Tumor  caused  by  dilated  stomach,  front  view]  . 

36.  Vascular,  polypoid  tumor  on  posterior  wall  of  stomach 

37.  Cancer  of  pylorus  with  dilatation  of  stomach-  and  duodenum 

38.  Cross-section  through  mucous  membrane  of  dilated  stomach 

39.  Total  scirrhous  cancer  of  stomach 

40.  Stomach  contents  from  a  case  of  cancer  of  stomach    . 

41.  [Boas  and  Oppler's  long  bacilli  found  in  cancer  of  stomach] 

42.  Colloid  cancer  of  lesser  curvature  of  stomach 

43.  Cancerous  cell-nest  raised  through  stomach  tube 

44.  Piece  of  mucous  membrane  resembling  cancerous  cell-nest . 

45.  Perforating  ulcer  of  stomach 

46.  Sketch  of  position  of  viscera  in  splanchnoptosis  . 


peri- 


256 
257 
258 
270 
272 
281 
326 
332 
333 
341 
353 
354 
379 
541 


DISEASES    OF  THE    STOMACH. 


CHAPTER   I. 

METHODS    OF   EXAMIjSTATIOISr. DETERMINATION    OF   THE    ACIDITY   AND 

ACIDS    OF    THE    CONTENTS    OF    THE    STOMACH. 

The  past  few  years  have  witnessed  sucli  prodigious  activity  in 
the  study  of  the  diseases  of  the  digestive  tract,  and  more  especially 
of  the  stomach,  that  we  may  now  run  some  risks  of  being  unable  to 
correctly  judge  what  has  been  accomplished,  as  we  may  be  unable 
to  separate  the  wheat  from  the  chaff.  Therefore,  while  pursuing  a 
branch  of  study  the  progress  of  which  is  so  active,  it  will  unques- 
tionably be  very  advantageous  if  we  pause  every  now  and  then  to 
take  an  account  of  stock,  to  appraise  what  is  novel  at  its  true  worth, 
and  to  rearrange  what  is  old  ;  so  that  we  may  retain  what  has  stood 
the  test  of  experience  and  discard  what  has  been  shown  to  be  mere 
hypothesis. 

It  affords  me  considerable  satisfaction  to  point  out  that  the 
views  which  I  have  repeatedly  expressed  on  former  occasions  on 
the  advances  in  our  knowledge  of  gastric  disorders  have  generally 
been  correct.  For,  unlike  many  other  investigators  in  this  field,  I 
have  maintained  that  we  ought  not  to  be  too  one-sided  in  laying 
undue  stress  upon  the  newly  acquired  knowledge  of  the  chemical 
processes  of  gastric  digestion  in  health  and  disease,  but  that,  so  far 
as  possible,  we  should  observe  and  make  use  of  all  the  symptoms. 
Thus,  at  the  conclusion  of  the  previous  editions  of  this  work  I 
always  urged  that  the  correct  diagnosis  of  a  gastric  disorder  was 
possible  only  after  the  most  careful  and  complete  consideration  of 
all  the  symptoms  and  the  employment  of  all  the  diagnostic  re- 
sources. This  opinion,  which  is  really  self-evident,  has  been 
strengthened  by  my  daily  increasing  practical  experience. 

As  always  occurs  under  similar  circumstances,  our  diagnostic 


2  DISEASES  OP  THE  STOMACH. 

armainentarmm  has  been  strengthened  hj  becoming  less  complicated. 
This  is  especially  true  of  the  chemical  procedures.  Hence  many 
things  which  were  fomierly  discussed  in  minute  details  may  now  be 
discarded,  or  dismissed  in  a  few  words.  On  the  other  hand,  I  pro- 
poses to  lay  more  stress  than  formerly  upon  the  so-called  physical 
methods  of  examination  and  upon  the  fundamental  principles  of 
dietetics. 

Before  entering  into  the  discussion  of  my  theme,  I  may  be  per- 
mitted to  make  a  few  brief  introductory  remarks.  The  methods 
which  have  recently  enabled  us  to  obtain  a  better  knowledge  of  the 
chemical  processes  in  the  stomach  have  thrown  a  light  upon  the 
pathology  of  dyspepsia  and  the  irregularities  of  gastric  digestion 
which  is  analogous,  comparing  a  small  matter  with  a  great  one,  to 
what  the  ophthalmoscope  did  in  its  day  for  the  retina  and  the  laryn- 
goscope for  the  interior  of  the  larjmx.  It  was  inevitable  that  this 
method  should  soon  be  favorably  received,  and  that  it  should  have 
been  very  extensively  used  during  the  past  few  years  in  hospital 
and  general  practice.  I  wish,  however,  to  state  that  not  too  much 
stress  should  be  laid  ujDon  these  procedures  as  belonging  to  a  spe- 
cialty. Throughout  this  work  I  will  be  able  to  show  that  the  tech- 
nique of  the  methods  which  are  in  use  is  by  no  means  difficult  to 
carry  out,  and  is  within  the  scojDe  of  every  physician  who  as  a  stu- 
dent has  learned  to  titrate,  to  test  acid  and  alkahne  solutions,  and  to 
place  a  test  tube  in  a  warm  chamber.  JSTaturally,  fewer  persons  are 
engaged  in  original  investigations ;  hence  the  examinations  do  not 
require  the  skill  characteristic  of  a  specialty,  which  can  only  be  ac- 
quired after  continuous  occupation  with  that  specialty.  But,  to 
obtain  and  analyze  stomach  contents  does  not  lie  beyond  the  scope 
of  the  dexterity  and  ability  which  every  physician  ought  to  possess. 
It  may  happen  that  one  is  consulted  especially  by  patients  with 
stomach  troubles  because  he  has  occupied  himseK  chiefly  with  the 
study  of  these  conditions,  and  has  hence  acquired  the  recantation  of 
possessing  a  special  experience.  But  this  alone  is  not  sufficient. 
Physicians  and  the  public  are  here  influenced  not  by  the  special  but 
by  general  medical  knowledge  ;  this  is  certainly  not  acquired  if  a 
physician  immediately  after  graduation  sets  himself  up  as  a  sj^ecial- 


THE   STOMACH   TUBE.  3 

ist  for  stomach  diseases.  In  the  course  of  this  book  it  will  be  seen 
how  closely  the  diseases  of  the  stomach  are  related  to  those  of  other 
organs,  how  complicated  this  relation  is,  how  often  the  symptoms 
are  deceptive,  how  frequently  in  an  apparent  stomach  disorder 
entirely  different  organs  are  really  involved.  Hence  it  is  my  firm 
conviction  that  it  is  impossible  to  find  truly  profitable  and  satis- 
factory special  occupation  in  the  treatment  of  the  diseases  of  the 
stomach  alone,  because  the  field  is  too  small,  and  the  technique  is 
so  easily  learned  and  is  so  limited  in  its  scope.  I  wished  to  premise 
these  remarks  because  such  cj^uestions  are  frequently  put  to  me. 

The  diagnosis  of  the  diseases  of  the  stomach  is  based,  as  in  other 
organs,  subjectively  upon  the  statements  of  the  patient,  and  objec- 
tively upon  the  results  of  our  examination.  I  shall  disregard  the 
former,  as  this  will  be  discussed  in  the  description  of  each  disease. 
For  the  latter  we  may  utihze,  first,  the  so-called  methods  of  physical 
examination — i.  e.,  inspection,  palpation,  auscultation,  and  mensu- 
ration ;  secondly,  the  analysis  of  the  chemical,  absorptive,  and 
mjotor  functions  of  the  organ — in  short,  the  investigation  of  the 
digestive  activity  of  the  stomach. 

•  First  of  all  I  shall  briefly  consider  the  chemical  processes  of 
digestion,  since  it  is  obvious  that  the  pathological  deviations  from 
the  normal  can  only  be  recognized  and  properly  treated  after  the 
normal  conditions  have  been  thoroughly  understood.  Formerly 
this  was  hardly  possible,  so  long  as  we  were  restricted  to  the  inade- 
quate external  signs  and  the  subjective  complaints  of  the  patients. 
But  now  a  very  important  factor  in  the  methods  of  examination 
has  been  supplied,  since  we  have  learned  how  to  obtain  the  contents 
of  the  stomach  at  any  time  in  an  easy  and  rapid  way,  which  is  also 
safe  and  convenient  to  the  patient. 

This  is  accomplished  by  means  of  the  hard  or  soft  stomach 
tubes,  and  with  the  general  use  of  these  instruments  the  new  era  in 
the  pathology  of  the  diseases  of  the  stomach  began. 

It  is  worthy  of  note  that  the  use  of  the  stomach  tube  is  by  no 
means,  as  is  supposed,  a  recent  acquisition,*     We  may  disregard 

*  Leube.     Die  Magensonde.     Die  Geschichte  ihrer  Entstehung  und  ihrer  Bedeu- 
tung  in  diagnostiseher  und  therapeutischer  Hinsicht.    Erlangen,  1879.     [A  most 


4  DISEASES  OF  THE  STOMACH. 

the  crude  manipulations  of  Fabricius  ab  Aquapendente  and  Kum- 
saeus  (1659),  who  invented  a  "  stomach  brush "  *  to  remove  the 
mucus  from  the  stomach,  "  so  that  at  that  time  there  .was  no  beer- 
company  at  which  some  did  not  apply  it  themselves  after  drinking 
heavily,  either  the  same  night  if  they  had  taken  too  much,  or  on 
tlie  following  morning,  if  they  were  distressed  with  the  thick  phlegm 
in  the  throat,  after  having  snored  out  their  intoxication."  f  In 
the  latter  half  of  the  previous  century  John  Hunter  introduced 
catheters  into  the  stomach,  but  only  to  inject  irritating  substances 
into  it.  The  English  surgeon,  ¥.  Bush,  was  the  first  to  attach  a 
pump  to  the  stomach  tube  to  evacuate  the  stomach  in  a  case  of 
opium  poisoning ;  this  discovery  is  attributed  by  others  to  Weiss, 
an  instrument  maker.  The  stomach  siphon  was  first  proposed  by 
Arnott :{:  in  1829,  and  then  by  Sommerville,  but  passed  into 
oblivion.  Kussmaul  *  again  directed  the  attention  of  the  profession 
to  the  stomach  tube  in  his  publications  in  186Y  and  1869,  on  the 
treatment  of  dilatation  of  the  stomach.  Meanwhile  it  had  been 
occasionally  recommended,  as  in  France  by  Blatin,  in  1832,  and  by 
Canstatt,  II  and  was  also  used  here  and  there.  It  was  always  a 
standing  though  only  privately  uttered  claim  of  Prof.  Frerich's 
clinic,  that  the  pump  had  regularly  been  used  long  before  Kuss- 
maul's  publications.  But,  as  is  well  known,  in  disputes  as  to 
priority  in  scientific  matters,  the  time  at  which  the  subject  in  ques- 
tion is  made  public  is  decisive,  and  hence  Kussmaul  deserves  the 
credit  of  having  again  called  the  attention  of  the  whole  medical  pro- 
fession in  an  impressive  way  to  the  use  and  benefits  of  the  stomach 
tube.     At  the  meeting  of  naturalists  at  Rostock,  in  1871,  Leube 

interesting  and  very  complete  history  of  the  stomach  tube  has  recently  been 
published  by  J.  C.  Hemmeter.  New  York  Medical  Journal,  December  28,  1895,  p. 
819.— Ed.] 

*  [Turck's  gyromele  is  a  modern  device  embodying  this  idea. — Ed.] 

f  J.  Chr.  Kundman.  Seltenheiten  der  Natur  und  Kunst,  etc.,  1737.  Quoted 
by  Leube. 

X  Quoted  by  Alderson,  On  the  Dangers  attending  the  Use  of  the  Stomach  Pump. 
Lancet,  January  4,  1879. 

*  Kussmaul,  in  Bericht  liber  die  41.  Versammlung  deutseher  Naturforscher  und 
Aerzte  zu  Frankfurt  a.  Main,  1867;  and  Ueber  die  Behandlung  der  Magenerweiter- 
ung  durch  eine  neue  Methode  mittelst  der  Magenpumpe.  Deutsch.  Arehiv  fiir 
klin.  Medicin,  Bd.  vi,  S.  455. 

II  Canstatt,  in  his  Jahresbericht  for  1841. 


THE  STOMACH  TUBE.  5 

asserted  tlie  possibility  of  using  it  for  diagnostic  purposes,  and,  as 
later  developments  proved,  opened  up  an  excellent  means  of  ex- 
amination. Yet  in  his  early  investigations  Leube  as  well  as  his 
predecessors  exclusively  used  a  stiff  tube,  or  a  rubber  tube  with  an 
elastic  but  more  or  less  rigid  whalebone  stylet.  This  procedure 
has  many  inconveniences  and  disadvantages.  Instead  of  this,  I  was 
the  first  to  show  that  a  very  soft  tube  without  any  stylet,  provided 
it  had  a  thick  wall  and  a  sufficient  firmness,  could  be  easily  intro- 
duced into  the  stomach  in  the  great  majority  of  cases  requiring 
examination.*  As  occurs  so  frequently,  this  was  the  result  of 
chance.  In  18Y5  a  man  who  had  poisoned  himself  with  prussic 
acid  was  brought  to  the  Frerich  clinic.  The  stomach  had  to  be 
washed  out  at  once.  ISTone  of  the  stiff  tubes  which  were  then  in 
use  was  at  hand,  so  I  cut  off  a  piece  of  gas  tubing,  rounded  off  the 
sharp  end,  cut  out  two  eyelets,  oiled  the  tube,  and,  although  the 
man  was  unconscious,  I  easily  succeeded  in  reaching  the  stomach. 
A  similar  procedure  was  pubhshed  later  by  Oser.f  It  is  now  quite 
universal  to  employ  only  soft,  vulcanized  rubber  tubes  like  Nek- 
ton's urethral  catheters.  They  have  been  used  in  France  since 
1880,  and  are  known,  as  tubes  Faucher.X 

The  expressions  oesophageal  sound,  oesophageal  tube,  stomach 
sound,  siphon  sound,  stomach  pump,  stomach  tube,  etc.,  are  indis- 
criminately used  by  writers,  and  not  in  their  true  meaning.  Sounds, 
strictly  sj)eaking,  are  instruments  whose  solidity  permits  the  trans- 
fer of  the  sense  of  touch  into  deep  and  inaccessible  places.  Hol- 
low instruments  can  only  be  indirectly  used  for  sounding,  if  their 
walls  are  thick  enough,  as,  for  example,  the  use  of  a  catheter  for 
exploring  the  bladder.  The  same  is  true  also  of  the  so-called  stiff 
oesophageal  and  stomach  tubes,  which  may  be  used  to  explore  the 
oesophagus  and  stomach  if  they  are  rigid  enough  and  are  rounded 

*  Ewald.  A  Ready  Method  of  washing  out  the  Stomach.  Irish  Gazette,  August 
15,  1874,  and  Berlin,  klin.  Wochenschr.,  1875,  No.  1. 

f  L.  Oser.  Die  mechanische  Behandlung  der  Magen-  und  Darmkrankheiten. 
Wiener  med.  Klinik,  1875;  and  Die  Magenaussptilung  mittelst  des  elastischen 
Schlauches.     Wiener  med.  Presse,  1887,  No.  1. 

X  [Faueher's  tubes  are  about  60  inches  long ;  the  external  diameter  is  f  to  f 
inch ;  the  walls  are  of  such  thickness  that  the  tube  can  be  bent  without  effacing  its 
lumen.  At  one  exti^emity  is  a  lateral  eye  with  two  orifices ;  to  the  other  extremity 
a  funnel  holding  about  a  pint  is  attached.     Welch. — Ed.] 


DISEASES  OF  THE  STOMACH. 


off  at  tlie  end.  But  this  use  is  merely  secondary,  as  tlieir  true 
function  is  indicated  by  tlieir  name  "  tubes " — i.  e.,  to  allow  the 
passage  of  fluids.  It  is  an  abuse  of  language  to  speak  of  a  siphon 
sound  {Reher sonde)  instead  of  a  stomach  tube  or  simply  a  stomach 
siphon.  In  the  following  pages  I  shall  speak  of  all  solid  instru- 
ments as  sounds,  and  of  the  hollow  tubes  with  more  or  less  rigid 
walls  as  stiff  oesophageal  or  stomach  tubes  {Schlundrohr  or  Magen- 
rohr\  and  of  the  flexible  tubes  (made  of  silk  or  rubber)  simply  as 
stomach  tubes  {Magenschlauch).^ 

If  the  tube  is  introduced  to  obtain  the  contents  of  the  stomach, 
it  is  naturally  of  primary  importance  that  these 
can  easily  enter  and  leave  the  tube ;  this  is  ac- 
complished by  having  as  many  and  as  large 
openings  as  possible  in  the  lower  portion.  The 
ordinary  stiff  tubes,  and  most  of  the  soft  ones  in 
general  use  till  now,  have  one  or  two  openings — 
eyelets  or  fenestrse,  as  they  are  called — near  the 
lower  end  ;  this  is  usually  a  bhnd  end  formed 
by  a  closed  tip  made  of  a  harder  material.  Un- 
less the  tube  is  very  carefully  cleansed,  all  kinds 
of  organic  substances  may  accumulate  here  and 
decompose.  To  avoid  these  objections  I  have 
the  tubes  made  of  different  thicknesses,  with 
the  lower  end  open,  and,  following  Schiitz's 
suggestion,  have  one  large  fenestra  very  low 
down  and  a  number  of  smaller  openings  about 
the  size  of  a  large  pin's  head  (Fig.  1).  In  this 
way  the  contents  of  the  stomach  may  easily 
enter  the  tube  from  all  sides,  and  can  be  very 
Fig.  1.  readily  obtained.     Furthermore,  the  tubes  can 


*  [It  is  surprising  how  often  the  expression,  stomach  pump,  is  used  by  writers 
where  the  soft  tube  is  referred  to.  A  very  striliing  example  of  this  fault  is  afforded 
by  the  recently  published  work  of  Sidney  Martin.  (The  Diseases  of  the  Stomach, 
London,  1895).  Here  the  word  stomach  pump  is  continually  used  ;  only  rarely 
do  we  encounter  the  terms  stomach  tube  or  siphon,  soft  tube,  etc.  This  is  greatly 
to  be  regretted,  as  such  carelessness  of  expression  may  tend  to  keep  up  the  popular 
dread  against  the  use  of  all  gastric  instruments  which  is  now  happily  disappear- 
ing.—Ed.] 


THE  STOMACH  TUBE.  7 

be  very  easily  cleansed  after  having  been  used.  These  tubes  are 
everywhere  known  as  Ewald's  stomach  tubes.* 

Tubes  made  of  braided  silk  varnished  over  have  also  been  em- 
ployed ;  they  are  somewhat  firmer  than  the  soft  rubber  tubes,  but 
are  much  less  rigid  than  the  stiff  ones.  At  my  suggestion  they 
have  been  made  after  the  same  model  as  that  above.  [Such  tubes 
are  very  delicate,  and  can  be  used  only  a  few  times  before  they  are 
ruined]. 

[Recurrent  stomach  tubes  have  been  devised  by  Hemmeterf 
and  others  for  lavage ;  the  cahber  of  the  outlet  tube  is  usually  too 
small  to  permit  their  use  for  diagnostic  purposes.] 

It  is  of  the  utmost  importance  that  all  tubes  be  kept  scrupu- 
lously clean,  nor  should  they  be  used  indiscriminately.  I  cleanse 
them  carefully  with  hot  water  after  every  introduction,  and  have 
them  washed  with  it  from  time  to  time.  They  are  kept  in  a  large, 
flat,  covered  glass  dish — like  the  large  culture  dishes  which  bacteri- 
ologists use — which  contains  a  solution  of  borax.  This  is  superior 
to  carbolic  acid,  thymol,  etc.,  since  it  imparts  no  bad  taste  to  the 
tubes.  Tubes  which  have  been  used  on  patients  with  or  suspected 
of  having  cancer  ought  to  be  specially  marked.  This  can  readily 
be  done  by  branding  them  with  a  hot  needle.  Patients  who  can 
afford  it,  and  who  require  prolonged  treatment,  may  provide  their 
own  instruments.:]: 


*  Although  I  had  already  published  an  exactly  similar  description  of  these  tubes 
in  the  first  edition  of  this  book  in  1888,  yet  Rosenheim,  of  Berlin,  in  the  Thera- 
peutische  Monatshefte,  August,  1892,  has  described,  in  almost  the  same  words  as 
above,  what  he  calls  his  own  important  modification  of  the  "  ordinary  tubes  "  for 
douching  the  stomach.  The  only  difference  is  that  he  has  substituted  an  addi- 
tional number  of  smaller  openings  for  the  large  lateral  f enestrum.  No  mention  is 
made,  however,  of  my  tubes.  If  Rosenheim  really  intended  to  construct  the  best 
possible  sprinkling  douche,  he  ought  also  to  have  closed  the  lower  opening,  which 
he  undoubtedly  refrained  from  doing  for  the  same  reasons  as  I  had.  Many  years 
ago  I  discarded  a  French  tube  which  had  only  small  lateral  openings ;  and  since  I 
have  successfully  douched  the  stomach  for  a  long  time  before  Rosenheim,  I  con- 
sider his  modification  as  entirely  superfiuous  for  this  purpose, 
t  [Hemmeter.  N.  Y.  Med.  Jour.,  December  28,  1895.— Ed.] 
X  [A  very  convenient  sterilizing  apparatus  for  stomach  tubes  has  been  devised 
by  Kutner.  An  illustration  of  it  may  be  found  in  Boas'  Magenkrankheiten,  3te 
Auflage,  Bd.  i,  p.  94,  or  Therapeut.  Monatshefte,  1894,  p.  397.  I  have  found  that 
keeping  stomach  tubes  in  the  solutions  recommended  by  Ewald  roughens  them 
after  a  time,  and  hence  I  prefer  to  keep  them  dry. — Ed.] 
2 


8  DISEASES  OP  THE  STOMACH. 

Dangers  of  Stomach  Tube. — It  is  self-evident  that  the  softer  the 
instrument  which  is  introduced  into  the  stomach  and  the  more 
rounded  the  edges  of  the  openings  are,  the  less  will  be  the  danger 
of  injuring  the  mucous  membrane.  This  occurs  more  easily,  and 
has  actually  occurred,  when  rigid  instruments  and  the  stomach  pump 
were  employed.  The  tearing  off  of  small  pieces  of  mucous  mem- 
brane has  frequently  been  reported,  as,  for  example,  by  Wiesner,* 
Yon  Ziemssen,f  Leube, ;{:  Schliep,*  and  others.  Cramer  \\  has  re- 
ported a  case  where  this  occurred  in  a  simple  lavage  of  the  stomach 
with  the  soft  tube.  This  writer  seems  to  be  unaware  of  the  fact 
that  Boas  ^  has  carefully  described  the  exfoliation  of  the  mucous 
membrane  which  occurs  in  chronic  gastritis,  and  has  employed  the 
microscopic  examination  of  these  particles  for  diagnostic  purposes.^ 
As  I  shall  show  later  on,  the  finding  of  these  bits  of  exfohated 
mucous  membrane  is  by  no  means  infrequent.  They  are  usually 
imbedded  in  blood-streaked  mucus.  JSTo  serious  consequences,  such 
as  bleeding  or  gastric  ulcers,  have  ever  resulted  from  them.  This 
is  probably  due  to  the  prompt  contraction  of  the  gastric  walls,  which 
closes  any  open  vessels  and  approximates  the  borders  of  the  dam- 
aged area. 

The  possibihty  of  such  an  occurrence,  and,  in  fact,  of  any  severe 
lesion  of  the  mucous  membrane,  is  reduced  to  a  minimum  by  the 
use  of  the  flexible  tube ;  and  in  this  way  there  has  been  removed  a 
serious  objection  which  prevailed  until  quite  recently  against  the 
internal  exploration  of  the  stomach  in  certain  conditions,  such  as 

*  Wiesner.  tJeber  der  Behandlung  der  Ectasie  mittelst  der  Magenpumpe.  Ber- 
liner klin.  Wochenschrift,  1870,  No.  1. 

f  Von  Ziemssen.  Zur  Technik  des  Loealbehandlung  des  Magens.  Deutsch. 
Archiv  fiir  klin.  Med.,  Bd.  x,  p.  66. 

X  Leube.    Die  Magensonde.     Erlangen,  1879,  p.  25. 

*  Schliep.  On  the  Stomach  Pump  in  the  Treatment  of  Chronic  Gastric  Catarrh. 
Lancet,  December  14,  1872. 

II  Cramer.  Die  Ablosung  der  Magenschleimhaut  durch  die  Sondirung  und 
ihre  Folgen.  Miinch.  med.  Wochenschr.,  1891.  Cramer  erroneously  states  that 
Leube  is  the  only  author  who  is  quoted  on  this  subject  in  the  newer  text-books  of 
Ewald  and  Rosenheim.  All  four  of  the  above  names  were  mentioned  in  the  first 
edition  of  this  work. 

^  Boas.    Magenkrankheiten,  3te  Auflage,  Bd.  i.,  p.  225. 

^  [An  elaborate  paper  on  this  subject  has  recently  been  published  by  Cohnheim, 
Die  Bedeutung  kleiner  Schleimhautstiickehen  fiir  die  Diagnostik  der  Magenkrank- 
heiten.   Boas'  Archiv  fiir  Verdauuugskrankheiten,  Bd.  i,  p.  274. — Ed.] 


THE   STOMACH  TUBE.  9 

cancer  and  ulcer,  where  bleeding  may  readily  occur.  Kegurgitation 
of  food  is  a  very  unpleasant  complication,  as  it  may  even  lead  to 
suffocation,  aspiration-pneumonia,  etc.*  This  may  be  guarded 
against  by  the  local  or  internal  use  of  cocaine  in  very  nervous  pa- 
tients. The  choking  sensation  is  much  less  marked  after  the  test 
breakfast  {vide  infra),  since  its  intensity  is  manifestly  regulated  by 
the  amount  of  the  ingesta,  and  the  masses  raised  are  smaller  and 
much  less  offensive.  It  ceases,  as  a  rule,  after  pouring  some  water 
into  the  stomach,  since  the  irritation  of  the  mucous  membrane  by 
the  tube  is  thus  removed.  In  most  cases,  however,  the  cause  is  not 
any  irritation  of  the  gastric  mucosa,  but  hypersesthesia  of  the 
pharynx,  which  gives  rise  to  retching  and  vomiting,  and  which 
may  readily  be  lessened  by  the  local  use  of  cocaine.  Finally,  when 
the  tube  is  removed  it  should  be  withdrawn  as  rapidly  as  possible. 
If  the  tube  is  pinched  between  the  thumb  and  index  finger  of  the 
right  hand  nothing  can  escape  during  its  withdrawal.  In  this  way 
we  may  prevent  any  aspiration  of  the  stomach  contents  into  the 
bronchi,  and  at  the  same  time  the  physician  soils  neither  himself 
nor  the  patient.  [Another  important  reason  for  pinching  the  tube 
during  its  withdrawal  is  that  we  thus  obtained  an  additional  few 
cubic  centimetres  of  stomach  contents.  Indeed,  it  not  infrequently 
happens  that  when  we  have  been  unable  to  siphon  any  stomach 
contents,  enough  may  be  obtained  in  this  way  to  make  a  superficial 
analysis.] 

I  personally  have  never  met  with  any  serious  accidents  — 
neither  large  haemorrhages  nor  any  other  mishap — and  can  agree 
with  Leube's  statement  that,  "taken  all  in  all,  the  passage  of  the 
tube  into  the  stomach  is  to  be  considered  an  operation  without 
risk " ;  f  but  I  would  modify  it  by  substituting  for  "  taken  all  in 
all "  the  expression  "  if  the  necessary  care  be  taken." 

Another  advantage  of  the  flexible  tubes  is  that,  in  introducing 
them,  it  is  absolutely  unnecessary  to  introduce  the  finger  into  the 
patient's  mouth,  thereby  sparing  him  the  always  unpleasant  gagging, 
and  obviating  the  danger  of  the  physician  having  his  finger  bitten. 

*  Emminghaus.    Einiges  uber  Diagnostik  und  Therapie  mit  der  Schlundsonde. 
Deutsch.  Archiv  fiir  klin.  Med,,  Bd.  ii,  p,  304. 
f  Leube,  loc.  cit.,  p.  40. 


10  DISEASES  OF  THE  STOMACH. 

In  introdiwing  flexible  tubes,  it  is  superfluous,  as  Oser  showed, 
to  apply  oil,  vaseline,  or  glycerin  to  tlie  outside  of  the  instrument. 
It  need  only  be  dipped  in  warm  water,  as  the  abundant  secretion  of 
saliva  by  the  patient  will  lubricate  it  sufficiently.  Let  the  patient 
[who  is  seated  in  a  chair  with  his  head  thrown  back  a  little]  open  his 
mouth,  push  the  tube  on  to  the  posterior  wall  of  the  pharynx  (the 
tube  is  sufficiently  rigid  to  permit  this),  and  then  ask  the  patient 
to  swallow  ;  the  tube  is  grasped  by  the  muscles  of  deglutition  and 
passes  without  any  difficulty  into  the  upper  end  of  the  oesophagus, 
its  passage  through  the  introitus  oesophagi  being  distinctly  felt ; 
then,  by  gently  pushing  the  tube,  it  speedily  reaches  the  stomach. 
At  times  a  slight  resistance  is  felt  at  the  cardia,  frequently  not.  By 
this  method  we  avoid  the  manipulations  in  the  patient's  mouth, 
which  are  unpleasant  both  to  the  latter  and  to  the  physician.  The 
procedure  is  much  simplified,  and  the  unpleasantness  and  excite- 
ment are  so  much  lessened  that,  among  the  many  thousand  patients 
examined  by  me,  I  can  scarcely  recall  a  case  in  which  I  was  unable 
to  introduce  the  tube,  provided,  of  course,  that  I  had  the  patient's 
co-operation.  With  a  little  patience  on  the  one  hand,  and  deter- 
mination on  the  other,  we  may  succeed  even  in  nervous  and  anxious 
subjects.  The  patients'  conduct  during  this  procedure  has  afforded 
me  an  excellent  test  of  the  strength  of  their  nerves,  and,  as  the  an- 
cients expressed  it,  of  their  sanguine  and  lymphatic  temperaments. 
In  very  sensitive  persons,  the  local  sensation  may  be  entirely  abol- 
ished by  painting  the  posterior  pharyngeal  wall  with  .a  10  to  20 
per  cent  cocaine  solution  a  few  minutes  before  introducing  the 
tube.  I  have  hardly  ever  found  this  necessary,  and  furthermore 
avoid  it  wherever  it  is  possible,  on  account  of  some  patients'  idio- 
syncrasy toward  the  drug.  But,  even  without  its  use,  I  may  safely 
assert  that  this  procedure  is  much  less  distressing  to  the  patient  than 
a  laryngoscopic  examination  without  cocaine,  as  the  latter  at  first 
sets  up  a  much  greater  irritation. 

Under  certain  conditions  it  may  be  impossible  to  pass  a  soft 
instrument  through  the  oesophagus,  even  though  it  be  free  from 
obstruction ;  then  there  is  also  the  active  resistance  of  the  insane, 
etc.  ;  finally,  we  may  encounter  mechanical  obstructions,  such  as 
unusual  narrowing  of  the  entrance  of  the  oesophagus,  due  to  bony 


THE  STOMACH   TUBE.  11 

protuberances  or  to  a  posterior  displacement  of  the  liyoid  bone  or 
nervous  spasm  of  the  oesophagus.  In  such  cases  it  is  necessary  to 
use  a  more  rigid  tube,  and,  according  to  the  resistance  to  be  over- 
come, we  may  try  either  one  of  the  above  described  silk  tubes,  or 
a  so-called  red  English  tube  made  of  catgut  varnished  over.  1  no 
longer  use  the  black  French  bougies,  which  were  formerly  so  popu- 
lar, as  they  wear  out  too  easily. 

The  majority  of  the  above  instruments  are  Y5  ctm.  [29^  inches] 
long,  so  that,  having  been  introduced  into  the  stomach,  only  a  small 
piece  is  left  projecting  between  the  teeth,  as  we  may  usually  reckon 
the  distance  from  the  incisor  teeth  to  the  lowest  point  of  the  greater 
curvature  as  being  60  to  65  ctm.  [23|  to  25|^  inches].  For  further 
manipulations,  this  small  projecting  piece  may  be  lengthened  before 
or  after  its  introduction  by  attaching  a  small  piece  of  glass  tubing 
with  a  suitable  length  of  rubber  tube  of  the  same  size ;  or,  if  the 
upper  end  of  the  stomach  tube  is  funnel-shaped,  we  may  insert  a 
hard  rubber  stopcock,  one  side  of  which  has  a  conical  end  with  a 
screw  thread,  while  the  other  side  is  a  smooth  tube  over  which  soft 
rubber  tubing  may  be  slipped.  For  cases  of  dilatation  of  the  stom- 
ach I  have  had  extra  long  tubes  made  with  a  length  of  95  ctm.  [3Y^ 
inches].* 

All  stiff  instruments  which  are  introduced  into  the  oesophagus 
or  stomach,  as  the  sponge  probang,  bougies,  etc.,  ought  to  be  held 
in  the  right  hand  like  a  pen  ;  the  left  index  finger  is  passed  into  the 
patient's  mouth  and  depresses  the  tongue,  the  tip  of  the  finger  pass- 
ing to  the  epiglottis  if  possible  ;  the  tube  is  then  passed  rapidly 
along  the  left  index  finger  to  the  posterior  pharyngeal  wall,  and 
then,  and  not  before,  by  raising  the  right  wrist  the  point  of  the  in- 
strument is  depressed  into  the  oesophagus.  The  more  quickly  and 
boldly  you  manipulate  the  more  easily  will  the  tube  pass,  and  the 
less  will  the  patient  be  annoyed.  The  danger  of  entering  the  larynx 
is  greatly  exaggerated,  and  the  detailed  accounts  given  about  it  in 


*  These  tubes  can  be  obtained  at  Miersch,  Berlin  W.,  Friedrichstrasse  66.  [At 
ray  request  the  Davidson  Rubber  Company  have  made  Ewald  stomach  tubes  with 
a  graduated  scale  on  the  tube  up  to  25  inches  ;  a  special  mark  is  made  at  the  16th 
inch  to  show  when  the  tube  enters  the  cardia.  These  tubes  may  be  had  of  J.  Camp' 
bell,  328  Lezington  Avenue,  N.  Y.— Ed.] 


12  DISEASES  OF  THE  STOMACH. 

most  text-books  are  quite  superfluous.  Under  normal  conditions 
tlie  entrance  to  the  larynx  is  at  once  reflexlj  closed  by  the  epiglottis. 
But  even  in  paralysis  or  ansestliesia  of  the  larynx,  and  other  con- 
ditions interfering  with  the  functions  of  the  epiglottis,  only  the 
greatest  clumsiness  will  cause  the  tube  to  enter  the  larynx  instead  of 
the  oesophagus.  But  even  if  it  should  occur,  the  marked  dyspnoea 
and  cyanosis  of  the  patient,  and  the  entrance  and  exit  of  air  through 
the  tube,  would  at  once  show  that  a  "  mistake  "  had  been  made.  At 
the  first  introduction  of  any  instrument  into  the  oesophagus  patients 
often  become  markedly  cyanotic,  because  they  believe  they  can  not 
breathe,  and  therefore  hold  their  breath  spasmodically.  Such  oc- 
currences must  not  be  confounded  with  the  above.  Holding  the 
breath  may  easily  be  differentiated  from  a  true  dyspnoea  by  getting 
the  patients  to  breathe  rhythmically  while  we  count  for  them. 

Having  introduced  the  tube,  our  next  task  is  to  obtain  the  con- 
tents of  the  stomach.  Here,  also,  the  past  few  years  have  witnessed 
a  great  simphfication.  Originally,  the  stomach  pump  was  used ; 
this  instrument  consists  of  a  pump  with  two  tubes — one  below,  the 
other  at  the  side ;  the  fluid  is  drawn  up  through  the  former,  and 
then  by  turning  the  piston,  or  by  some  similar  arrangement  of  the 
valves,  it  is  evacuated  through  the  latter.  Other  even  more  com- 
plicated apparatus  has  been  devised  which,  as  the  proverb  reads, 
make  five  quarters  out  of  a  mile  !  They  all  require  such  an  array 
of  bottles  and  glass  tubes  as  from  the  very  beginning  to  preclude 
their  practical  use. 

Aspiration  and  expression  are  the  methods  which  we  now  gener- 
ally employ  for  obtaining  stomach  contents.  For  the  purpose  of 
aspiration  we  attach  the  upper  end  of  the  tube  by  means  of  a  con- 
necting tube  of  hard  rubber  or  glass  to  a  pear-shaped  rubber  bag 
(like  a  Politzer  bag),  which  has  an  upper  opening  about  the  size  of 
the  little  finger.  The  bag  is  attached  after  it  has  been  squeezed  to- 
gether ;  in  expanding,  it  aspirates  the  stomach  contents  so  long  as 
subjected  to  the  ordinary  atmosj^heric  pressure.  This  bag  may  also 
be  used  for  the  reverse  ;  namely,  by  filling  it  with  air  or  water, 
attaching  it  to  the  tube,  and  then  by  squeezing  it  gently  we  may 
succeed  in  dislodging  any  pieces  of  food  which  may  obstruct  the 
lumen  of  the  tube,  as  is  recognized  by  the  cessation  of  the  resistance 


THE  EXPRESSION  METHOD. 


13 


caused  by  the  plug.  Boas  *  has  suggested  tlie  use  of  a  rubber  bulb 
with  a  short  rubber  tube  on  either  side  ;  one  of  these  is  attached  to 
the  stomacli  tube  by  means  of  a  small  piece  of  glass  tubing  ;  on  the 
other  is  a  pinchcock  (Fig.  2).     A  vacuum  is  obtained  by  compress- 


ing the  bulb  while  the  cock  is  open  ;  when  the  latter  is  closed  the 
contents  of  the  stomach  will  be  sucked  up  into  the  bulb.  The  cock 
is  now  opened  while  the  tube  on  the  other  side  of  the  bulb  is  com- 
pressed ;  by  squeezing  the  bulb,  whatever  has  been  aspirated  may 
be  expelled  into  a  vessel  held  under  the  free  end  of  the  tube  with 
the  cock.  I  have  not  found  this  instrument  as  convenient  as  the 
Politzer  bag,  since  both  hands  are  needed  to  open  the  pinchcock. 
Both  methods  are,  however,  good.  [My  own  experience  is,  that 
Boas'  bulb  is  far  superior  to  the  Politzer  bag.  Its  manipulation  is 
exceedingly  simple  and  easy  ;  with  it  we  may  often  be  able  to  start 
the  siphonage  where  expression  fails ;  and,  finally,  it  is  more  easily 
cleaned  than  the  bag  can  be.  Aspiration  may  also  be  done  by 
attaching  the  stomach  tube  to  the  vacuum  bottle  of  Potain's  as- 
pirating apparatus,  but  the  caution  must  be  taken  of  using  a  low 
vacuum.] 

The  Expression  Method. — But  usually  all  these  manipulations  are 
unnecessary.  Some  time  ago  Dr.  Boas  and  myself  showed  that  the 
stomach  contents  could  be  obtained  at  any  time  by  means  of  the 
abdominal  pressure,  since  the  straining  of  the  patient  suffices  to 
drive  the  contents  of  the  stomach  into  the  tube,  provided  they  are 


*  I.  Boas.     Allgemeine  Diagnostik  und  Therapie  der  Magenkrankheiten.    3te 
Auflage,  Bd.  i,  p.  138. 


14  DISEASES  OF  THE  STOMACH. 

sufficiently  fluid,  so  tliat  the  lumen  of  the  tube  is  not  occluded.* 
It  is  frequently  erroneously  stated  that  the  physician  must  press 
with  his  hand  upon  the  patient's  abdomen.  Since  then  the  method 
has  been  tried  by  many  others  with  excellent  results,  and  has  been 
designated  the  Ewald  Exj)ression  Method  {Die  Ewald^sche  Expres- 
sionsmethode).  It  is  true  that  some  one  may  now  and  then  have 
observed  that  the  stomach  contents  were  forced  from  the  tube  dur- 
ing acts  of  coughing,  etc. ;  yet  Boas  and  myself  may  claim  the 
credit  of  having  systematized  the  method,  and  by  its  means  of  hav- 
ing greatly  simplified  the  technique. 

Martins  f  states  that  "  Ewald's  method  was  the  first  one  with 
which,  without  the  slightest  danger,  sufficient  stomach  contents  could 
be  obtained  at  any  time  for  examination  from  every  stomach  case." 
In  fact,  the  introduction  of  the  tube  for  diagnostic  purposes  is  being 
employed  more  and  more  by  physicians,  and  is  so  well  known  to 
the  laity,  that  not  infrequently  patients  in  whom  the  chemical  ex- 
amination of  the  stomach  contents  is  unnecessary  reproachfully  ask 
"  whether  they  will  not  be  pumped  out."  Indeed,  with  but  very 
few  exceptions  I  should  reproach  myself  if  in  any  doubtful  case  I 
had  neglected  to  employ  this  method,  which,  when  properly  applied, 
is  so  absolutely  free  from  danger. 

Epstein  %  has  successfully  applied  the  treatment  with  the  stom- 
ach tube  in  very  small  children,  even  in  infants ;  the  tube  was,  of 
course,  of  a  corresponding  size — i.  e.,  a  !N^elaton  catheter,  iN^os.  8, 
9,  and  10  (French).  Leo  *  and  others  have  used  this  method  for 
the  systematic  study  of  the  functions  of  the  stomach  in  suckling 
infants,  where  its  employment  is  so  very  simple. 

By  proper  use,  as  above  mentioned,  I  would  have  understood 
that  whenever  the  jpossibility  exists  that  the  use  of  the  abdominal 
pressure  may  produce  hcem^orrhage  from,  or  even  tearing  of,  the 
gast/ric  or  intestinal  mucosa,  the  tube  must  not  be  employed  ;  or,  if 

*  Ewald  und  Boas.     Beitrage  zur  Physiologie  und  Pathologie  der  Verdauung. 
Virchow's  Archiv,  Bd.  ci,  pp.  325-375 ;  ibid.,  Bd.  civ,  pp.  271-305. 

•f  Martius  und  Liittke.     Die  Magensaure  des  Menschen,  1892,  p.  4. 
X  Epstein.    Ueber  Magenausspiilung  bei  Sauglingen.     Archiv  fiir  Kinderheil- 
kunde,  1883,  Bd.  iv,  S.  325. 

*  Leo.     Ueber  die  Function  des  normalen  und  kranken  Magens,  etc.,  im  Saug- 
lingsalter.     Berl.  klin.  Wochenschrift,  1888,  No.  49. 


THE  STOMACH  TUBE.  15 

it  is,  only  aspiration  after  preliminary  cocainisation  should  be  re- 
sorted to.  The  diseases  in  which  these  rules  hold  good  are  ulcera- 
tive processes  in  the  stomach,  severe  organic  diseases  of  the  heart, 
aortic  aneurisms,  hsemorrhagic  diatheses,  etc.,  concerning  which  I 
shall  speak  in  more  detail  later  on.  ITevertheless  here,  as  in  every 
procedure  which  is  not  absolutely  a  matter  of  indifference,  unfortu- 
nate accidents  may  arise  for  which  neither  the  physician  nor  the 
method  ought  to  be  held  responsible.  Such  a  case  I  reported  to 
the  Berlin  Medical  Society ;  *  a  number  of  others  have  been  pub- 
hshed  by  W.  S.  Fen  wick,  f  Although  such  occurrences,  which, 
after  all,  concern  only  decrepit  patients  whose  hves  hang  in  the 
balance,  should  warn  us  to  be  careful  at  all  times,  yet  they  should 
not  make  us  discard  the  method,  any  more  than  anaesthetics  ought 
to  be  abandoned  because  of  the  occasional  deaths  under  narcosis. 

It  sometimes  happens  that,  although  the  stomach  is  full,  none  of 
its  contents  can  be  obtained  by  any  of  these  methods.  This  may  be 
due  to  an  occlusion  of  the  fenestrse  of  the  tube,  either  by  a  prolapse 


*  Bwald.  Ein  Fall  von  Aneurysma  Dissecans.  Berl.  klin.  Woehensehr.,  1890, 
p.  694.  A  man  who  was  suspected  of  having  a  cancer  of  the  stomach  presented 
himself  to  have  the  stomach  tube  introduced  in  order  to  obtain  some  of  the  gastric 
contents  for  examination.  No  tumor  could  be  felt,  yet  he  was  emaciated  and  ca- 
chectic. Slight  tenderness  on  pressure  in  the  epigastrium.  Heart  and  lungs  nor- 
mal. After  introducing  the  tube  very  easily,  the  patient  was  asked  to  bear  down  ; 
at  that  instant  he  suddenly  fell  back,  became  pale  and  cyanotic,  and  died  within  a 
few  minutes.  There  was  no  hsematemesis,  nor  was  there  any  blood  on  the  tube. 
During  the  last  few  moments  of  life  a  rapid  increase  in  the  area  of  cardiac  dullness 
and  a  loud  friction  sound  over  the  heart  could  be  made  out.  The  diagnosis  made 
was  haematopericardium,  resulting  from  rupture  or  perforation  of  an  aneurism. 
The  autopsy  revealed  the  presence  of  a  dissecting  aneurism  at  the  beginning  of  the 
ascending  aorta,  just  above  the  aortic  valves  and  still  within  the  pericardium,  just 
where  the  latter  is  reflected.  At  this  spot  the  wall  of  the  aneurism  was  torn,  and 
it  was  here  that  the  blood  had  entered  the  pericardial  cavity.  The  stomach  and 
oesophagus  were  absolutely  intact  and  were  free  from  any  neoplasm.  It  must  re- 
main an  open  question  whether  the  introduction  of  the  tube  had  anything  to  do 
with  the  rupture  of  the  aneurism.  If  we  consider  all  the  factors  of  the  act  of  bear- 
ing down,  it  would  appear  that  it  would  not  produce  such  a  result ;  however,  it 
would  not  cause  an  increase  of  the  blood  pressure  in  the  aorta  above  the  semilunar 
valves,  but  would  rather  exert  pressure  on  the  exterior  of  the  vessel.  At  all  events 
the  death  occurred  while  the  tube  was  used. 

t  W.  Soltau  Fenwick.  Some  of  the  Dangers  of  Washing  Out  the  Stomach; 
Practitioner,  April,  1892.  Among  other  cases,  Fenwick  also  speaks  of  several  fatal 
cases  of  tetany  which  occurred  immediately  after  lavage.  Had  the  stagnating  stom- 
ach contents  been  thoroughly  removed  at  an  early  period,  the  tetany  would  have  been 
prevented.    Consequently  these  cases  speak  more  in  favor  of  lavage  than  against  it. 


16 


DISEASES  OP  THE   STOMACH. 


of  the  mucous  membrane,  or  they  may  be  plugged — botb  of  these 
occur  rarely  with  my  method ;  or  the  tube  may  have  been  intro- 
duced too  far  and  has  curled  around  along  the  greater  curvature, 
and  thus  the  end  is  above  the  level  of  the  contents  of  the  stomach, 
as  is  shown  in  Fig.  3.  This  is  easily  remedied  by  withdrawing  the 
tube  a  little. 

In  rare  cases  it  may  also  happen  that  at  a  time  after  the  test 
breakfast,  when  the  stomach  is  usually  full,  the  organ  is  found 
empty,  and  hence  nothing  can  be  expressed.     In  such  cases  the 

transfer  of  the  inges- 
ta  into  the  intestines 
is  unusually  rapid  ; 
this  is  generally  due 
to  a  hyperkinesis  of 
the  muscular  fibers, 
a  condition  which 
will  be  referred  to  in 
the  discussion  of  the 
gastric  neuroses. 

Although  this 
method  of  expres- 
sion, as  I  have  called 
it,  can  usually  be  car- 
ried out  very  readily 
after  one  has  acquired 
a  httle  experience,  yet  I  must  not  neglect  to  tell  you  that  in  some 
cases  it  is  not  successful.  Thus  this  may  happen  where  the  abdom- 
inal walls  are  so  relaxed  that  their  pressure  can  not  be  brought  into 
play ;  then,  there  are  also  some  persons  who  have  so  httle  control 
over  their  muscles  that  they  can  not  bear  down  when  they  are  told 
to  do  so.  Hence  this  method  of  expression  may  not  be  successful, 
or  at  least  not  till  after  several  attempts ;  yet,  taken  all  together, 
this  occurs  in  scarcely  five  per  cent  of  the  cases. 

I  may  dismiss  with  mere  mention  the  various  procedures  which 
have  been  proposed  by  Spallanzani,  Edinger,  Spath,  Einhom,  and 
Kornfeld.  Small  quantities  of  stomach  contents  are  obtained  by 
having  the  patients  swallow  small  balls  of  compressed  elder  pith, 


Fig.  3. 


SUBSTITUTES  FOR  THE  TUBE.  17 

sponges,  or  silver  buckets  whicli  are  attaclied  to  a  string.  They 
have  no  practical  value,  because  the  largest  quantities  of  stomach 
contents  which  can  be  obtained  with  them  are  too  small  for  a  com- 
plete analysis ;  while,  on  the  other  hand,  the  inconvenience  which 
they  cause  the  patient  is  scarcely  less  than  that  due  to  the  introduc- 
tion of  the  tube. 

Giinzburg*  and  Sahlif  have  proposed  methods  by  means  of 
which  conclusions  as  to  the  completeness  of  gastric  digestion  are 
drawn  in  an  indirect  ^vay  without  withdrawing  any  stomach  con- 
tents. Some  substance,  like  potassic  iodide,  which  is  readily  ab- 
sorbed, is  introduced  into  the  stomach  during  digestion  after  hav- 
ing been  inclosed  in  a  special  way  in  a  fibrin  capsule.  The  length 
of  time  which  elapses  until  the  appearance  in  the  saliva  of  the 
potassic  iodide  which  has  been  absorbed  after  the  digestion  of  the 
fibrin  capsule  is  used  as  a  standard  for  determining  the  good  or 
bad  condition  of  the  digestion  in  toto.  It  must  be  apparent  that 
this  method  can  never  give  any  exact  information  as  to  the  cause  of 
any  particular  stage  of  digestion,  nor  the  relation  of  the  different 
phases ;  it  does  not  even  give  any  absolute  indications  concerning 
digestion  in  the  stomach,  as  there  are  no  criteria  whether  the  capsule 
was  digested  in  the  stomach  or  intestines.  I  shall  therefore  refrain 
from  giving  exact  details  as  to  the  somewhat  complicated  methods 
of  preparation  of  these  capsules,  which  even  Sahli  himself  con- 
siders only  as  complementary  to  the  exact  methods  of  analysis. 
The  employment  of  potassic  iodide  capsules  for  testing  the  absorp- 
tive powers  of  the  stomach  will  be  considered  later  on.:}: 

It  is  self-evident  that  in  the  examination  of  the  contents  of  the 
stomach  a  method  which  is  as  uniform  as  possible  should  be  fol- 
lowed. The  activity  of  the  gastric  secretion  depends,  imitatis 
mutandis^  upon  the  food  eaten.      The  quantity  is  abundant  if  a 

*  Griinzburg.  Ein  Ersatz  der  diagnostischeu  Magenausheberung.  Deutsche 
med.  Wocheaschr.,  1889,  No.  41. 

f  Sahli.  Ueber  eine  neue  Untersuchungsmethode  der  Verdauungsorgane  und 
einige  Resultate  derselben.     Schweizer  Corresp.-Blat.,  1891,  No.  3. 

X  [Other  indirect  methods  of  studying  the  changes  in  the  gastric  juice  have 
been  suggested.  These  are  based  upon  changes  in  the  acidity  of  the  urine  and 
the  amount  of  indican.  See  page  163.  A  good  resume,  of  these  indirect  meth- 
ods has  been  given  by  Boardman  Reed,  Medical  News,  January  18,  1896,  p. 
57.— Ed.] 


18  DISEASES  OP  THE  STOMACH. 

good  opportunity  is  offered  for  free  secretion.  An  abundance  of 
food  calls  forth  a  greater  activity  of  tlie  glands  than  a  scanty  diet, 
till  the  food  present  is  saturated  with  the  secreted  juice.  There- 
fore different  results  will  be  obtained  if  the  examinations  are  made 
after  varying  intervals  and  after  different  kinds  of  food.  The 
neglect  of  this  point  was  the  cause  of  the  great  discrepancies  be- 
tween the  various  writers  up  to  a  short  time  ago  ;  hence  it  is  abso- 
lutely indispensable  that  the  interval  after  the  meal  and  the  diet 
should  always  be  the  same,  if  the  results  are  to  be  of  any  value  for 
comparison. 

The  question  naturally  arises,  What  is  the  normal  course  of  the 
secretion  in  human  heings  f  A  continuous  series  of  experiments 
on  the  successive  phases  of  digestion  in  animals,  as  well  as  in  hu- 
man beings,  had  never  been  made  till  Dr.  Boas  and  myself  made 
ours  on  the  latter  some  years  ago.  First  of  all  we  corroborated  the 
results  of  Tiedemann  and  Gmelin  (1826)  and  others,  that  there  is 
normally  no  gastric  juice  in  the  stomach  when  fasting ;  that  some 
kind  of  irritation  of  the  gastric  mucous  membrane  is  necessary  to 
produce  the  secretion,  either  by  the  simple  introduction  of  a  sound 
or  tube,  as  in  very  nervous  persons,  or  by  giving  some  water,  pep- 
per, etc.  Thus,  for  example,  Edinger  *  found  that  in  13  out  of  15 
cases  there  was  no  trace  of  hydrochloric  acid,  and  in  the  other  two  a 
"  by  no  means  positive  "  trace  of  it.  He  used  the  old  method  of 
Spallanzani,  in  which  the  subjects  swallowed  pieces  of  sponge  com- 
pressed to  the  size  of  a  pill,  and  attached  to  a  silk  thread.  Con- 
cerning this  it  must  be  stated  that,  in  persons  who  have  not  eaten 
for  an  unusually  long  time,  the  introduction  of  the  tube  may  not 
cause  a  secretion  of  gastric  juice,  but  instead  a  regurgitation  of  bile 
and  other  contents  of  the  duodenum.  This  is  not  a  normal  occur- 
rence, as  will  easily  be  perceived  from  the  standards  to  be  given 
later  on.    Schreiber  f  and  Rosin,  ^  after  very  thorough  experiments, 

*  Edinger.  Zur  Physiologie  und  Pathologie  des  Magens.  Deutsch.  Archiv  fiir 
klin.  Med.,  Bd.  xxix,  1881. 

f  J.  Schreiber.  Die  spontane  Saftabsciieidung  des  Magens  im  Ntichternen  und 
die  Saftsecretion  des  Magens  im  Fasten.  Arch,  fiir  experim.  Pathologie  und 
Pharmakologie,  Bd.  xxiv,  S.  365. 

X  H.  Rosin.  Ueber  das  Secret  des  niichternen  Magens.  Deutsche  med.  Woch' 
enschr.,  1887,  No.  47. 


IS  THE  GASTRIC  SECRETION  CONTINUOUS?  19 

liave  recently  claimed  tliat  tlie  secretion  in  tlie  stomacli  is  con- 
tinuous. At  all  events,  it  was  found  that  in  14  out  of  15  persons 
examined  for  this  purpose  from  2  to  50  c.  c.  [f  3  ss.  to  5  jf ]  of  ^ 
fluid  containing  hydrochloric  acid  could  be  expressed  from  the 
stomach  when  free  from  food ;  the  fluid  was  usually  clear  as  water, 
mth  very  little  potash  and  no  remnants  of  food ;  in  a  few  cases  it 
was  colored  green  or  yellow.  Likewise,  in  10  out  of  11  persons 
who  had  fasted  seven  hours,  some  of  them  even  the  greater  part  of 
the  day,  a  fluid  containing  hydrochloric  acid  could  always  be  ob- 
tained by  expression,  repeated  at  a  few  hours'  interval.  In  the 
cases  examined  by  Kinnicutt,*  2  c.  c.  of  stomach  contents  contain- 
ing free  hydrochloric  acid  was  found  in  one  case,  10  c.  c.  in  another. 
Leo,t  who  found  hydrochloric  acid  "  almost  without  exception  "  in 
the  stomachs  of  suckHng  infants,  considers  it  a  residue  of  the 
previous  process  of  digestion,  while  Rosenheim ;{:  and  Kinnicutt 
agree  perfectly  with  my  results  that  normally  the  stomach  contains 
only  traces  of  hydrochloric  acid  (never  over  0'04:  per  thousand  *). 
I  can  not  admit  that  Schreiber's  experiments  are  convincing,  and 
that  the  glands  of  the  stomach,  unlike  all  other  secreting  glands, 
are  active  without  any  specific  stimulation,  somewhat  like  a  steam 
engine  "  going  dead  slow,"  I  still  consider  that  the  simple  act  of 
introducing  the  tube  in  most  persons  who  have  not  become  accus- 
tomed to  it  by  long  practice  causes  a  reflex  from  the  mouth  down- 
ward, and  this  reflex  action  will  sufiice  to  call  forth  a  more  or  less 
marked  secretion  of  gastric  juice.  Furthermore,  this  will  occur 
more  readily  the  longer  the  person  has  remained  hungry  beyond 
the  usual  time  of  eating,  exactly  as  happens  in  the  salivary  glands 
of  dogs,  which,  when  a  piece  of  meat  is  held  before  them,  secrete 
the  more  abundantly  the  longer  they  have  been  starved.  Proof  of 
this  was  afforded  me  in  five  patients  who  were  accustomed  to  the 

*  Kinnicutt.  Diagnosis  of  Diseases  of  the  Stomach.  Transactions  of  the  Asso- 
ciation of  American  Physicians,  vol.  v,  p.  216. 

f  Leo,  loc.  cit. 

X  T.  Rosenheim.  Ueber  die  Siiuren  des  gesunden  und  kranken  Magens  bei 
Einfiihrung  von  Kohlenhydraten.     Virchow's  Archiv,  Bd.  cxi,  S.  419. 

*  [0"04  per  thousand,  or  0"04  pro  mille,  as  it  is  usually  expressed  in  German, 
equals  ysisw^-  This  is  a  very  convenient  way  of  expressing  these  high  fractions  in 
the  decimal  system.  They  can  easily  be  converted  back  into  fractions  by  remem- 
bering that  1  pro  mille  (or  O'l  per  cent.)  equals  xoVo- — Ed.] 


20  DISEASES  OF  THE  STOMACH, 

passage  of  the  instrument.  I  passed  the  tube  while  the  patients 
were  in  bed  a  short  time  before  breakfast,  but  I  obtained  only 
small  quantities  of  clear  mucus,  at  times  of  a  yellow  color.  This 
mucus,  although  having  a  feeble  acid  reaction  several  times,  never 
gave  a  reaction  with  the  tropaeolin  or  the  phloroglucin-vanillin  tests. 
It  may  be  objected  that  these  were  patients  with  diseased  stomachs ; 
yet  they  always  secreted  gastric  juice  with  hydrochloric  acid  after 
taking  food.  It  is  self-evident  that  patients  who  are  suffering  from 
hypersecretion  of  the  gastric  juice,  whose  stomachs,  therefore,  are 
never  empty,  but  always  contain  a  certain  amount  of  secretion, 
ought  not  to  be  employed  for  such  experiments ;  on  the  other  hand, 
it  is  wrong  to  introduce  distilled  water  into  the  stomach  and  then 
aspirate  it,  because  this  produces  a  more  or  less  energetic  secretion 
of  hydrochloric  acid.  At  all  events,  the  contradictory  results  given 
by  the  above  writers  show  that  idiosyncrasy  causes  some  to  react 
more  easily  than  others,  and,  as  we  shall  see  later  on,  this  may 
under  certain  conditions  even  lead  to  a  pathological  increase  of  the 
secretion. 

[There  has  recently  been  considerable  discussion  as  to  the  con- 
tents of  the  stomach  while  fasting,  for  the  reason  that  the  answer  to 
this  question  is  of  importance  in  the  condition  known  as  continuous 
hypersecretion  (see  Chapter  XI).  Probably  the  best  results  obtained 
are  those  of  Martius,*  who  made  experiments  on  16  healthy 
soldiers ;  while  fasting,  the  tube  was  introduced  and  the  contents  of 
the  stomach  were  aspirated.  In  order  to  eliminate  any  irritation 
of  the  gastric  mucosa  from  the  tube  the  manipulations  were  per- 
formed as  rapidly  as  possible.  On  an  average  only  5  seconds  were 
needed  to  insert  the  tube  and  T  to  8  seconds  for  aspiration. 
In  all  cases  Martius  obtained  stomach  contents  which  contained 
hydrochloric  acid;  the  quantity  of  the  stomach  contents  varied 
from  3  to  30  c.  c.  (5tV-J)|  ^^^  acidity  from  10  to  40  (0-4:  to 
1*5  per  mille  HCl).  Schiile  f  experimented  on  9  subjects,  6  of 
whom  had  previously  been  trained.  In  31  out  of  34  trials  the 
stomach  contained  2  to  23  c.  c.  (  3 1— vj)  of  acid  fluid.     Free  hydro- 

*  [Mai-tius.     Ueber  den  Inhalt  des  gesunden  nuchternen   Magens.     Deutsch. 
med.  Wochenschr.,  Aug.  9,  1894,  p.  628.— Ed.] 

f  [Schiile.     Berl.  kliii.  Wochenschr.,  1895,  No.  53.— Ed.] 


THE  TEST  MEALS.  21 

cliloric  acid  was  only  present  7  times ;  mucus,  bile,  peptones,  and 
pepsin  were  occasionally  found.  The  cause  of  the  presence  of 
this  fluid  must  be  the  saliva  and  pharyngeal  secretions  which  are 
swallowed  during  sleep.  He  concludes  that  the  presence  of 
hyperacid  fluid  in  amounts  over  50  c.  c.  is  pathological.] 

Test  Meals. — For  testing  the  functions  of  the  stomach  we  give 
the  patients  various  meals,  some  of  which  are  simple,  others  are 
larger;  but,  so  far  as  possible,  the  various  meals  should  be  uni- 
formly prepared.  The  test  hreakfast  {Probefruhstuck)  of  Ewald 
and  Boas  consists  of  an  ordinary  dry  roll  and  a  definite  quantity — 
^  litre  [f^x] — of  fluid,  either  simply  warm  water  or  weak  tea 
[without  milk  or  sugar].  (Tea  sometimes  has  a  feeble  acid  reac- 
tion, depending  on  the  province  from  which  the  tea  leaves  come.) 
According  to  Konig's  analysis,  such  rolls  contain  7  per  cent  nitro- 
gen, 0*5  per  cent  fat,  4  per  cent  sugar,  and  52*5  per  cent  non- 
nitrogenous  extractive  substances,  to  which  1  per  cent  ash  must  be 
added.  The  roll  is  thus  a  mixture  of  the  various  nutritious  ingre- 
dients, and  is  made  up  here  [Berlin]  of  a  tolerably  uniform  weight, 
about  35  grammes  [540  grains].  The  test  breakfast  thus  includes 
albuminoids,  sugar,  starches,  non-nitrogenous  extractives,  and  also 
salts ;  the  tea  belongs  to  that  group  of  foods  which  are  of  consid- 
erable importance  to  the  gastric  secretion.  By  means ,  of  this 
breakfast  we  can  offer  the  stomach  all  the  ingredients  which  are 
usually  taken,  with  the  great  advantage  that  they  are  liquefied 
in  a  relatively  short  time,  or  at  least  they  are  softened  sufiiciently 
to  permit  their  passage  through  the  tube ;  while  if  solid  food 
like  meat  is  given,  the  openings  in  the  tube  are  very  easily 
plugged. 

This  also  explains  why  many  can  not  dispense  with  the  stomach 
purnp,  which  naturally  gives  greater  suction  power.  The  test 
breakfast  can  be  taken  by  most  patients  with  gastric  disorders, 
many  of  whom  would  be  unable  to  eat  a  larger  meal.  My  method 
has  the  additional  advantage  of  great  cleanliness.  Even  should  the 
patient  vomit,  as  occurs  occasionally  in  a  very  few  cases,  the  vomit 
does  not  consist  of  fatty,  offensive,  and  viscous  masses,  as  when  a 
large  meal  is  taken,  but  only  of  comparatively  clean  morsels  of 
bread.     These  advantages  have  caused  the  method  to  be  very  popu- 


22  DISEASES  OP  THE  STOMACH. 

lar.  On  tlie  other  hand,  it  must  not  be  forgotten  that  such  a  mod- 
erate meal  makes  a  very  slight  demand  on  the  action  of  the  viscus, 
and  a  stomach  which  may  prove  capable  of  digesting  this  moderate 
meal  may  not  secrete  enough  for  a  more  complicated  diet.  This 
objection  apphes  also  to  the  meal  of  milk  and  bread  which  has  been 
proposed  by  Klemperer,*  and  with  even  greater  force  to  the  one- 
sided administration  of  small  quantities  of  albumen  only  (the  whites 
of  one  or  two  hard-boiled  eggs),  as  proposed  by  Jaworski.  It  is 
for  this  reason  that  I  deny  the  value  of  such  a  meal  to  test  all  the 
digestive  functions  of  the  stomach.  If  we  have  given  the  test 
breakfast,  and  still  desire  to  apply  severer  tests,  nothing  forbids  the 
use  of  another  kind  of  food  to  ascertain  whether  the  latter  is  also 
properly  digested,  f 

Larger  meals,  like  the  test  dinner  {Probemittaghrod),  to  be 
taken  at  noon,  have  been  employed  by  other  observers  (Leube, 
Kiegel,  Germain  See).  The  test  dinner  consists  of  an  ordinary 
[German]  midday  meal  of  bouillon,  barley  or  flour  soup,  a  moder- 
ate piece  of  beefsteak,  and  some  bread.  J^aturally  a  uniform  quan- 
tity should  be  given  at  these  meals — about  400  grammes  [about  13 
fl.  oz.]  of  soup,  60  grammes  [2  oz.]  scraped  beef,  and  50  grammes 
[If  oz.]  wheat  bread.  This  is  not  so  easily  carried  out,  and  the 
same  interval  should  also  be  allowed  to  elapse  before  the  examina- 
tion. With  the  test  breakfast  digestion  is  at  its  height  within  one 
hour  after  eating,  and  under  normal  conditions  can  be  evacuated  in 
a  liquid  condition  ;  but  in  the  large  meals  either  no  digestion  at  all, 
or  very  little,  will  have  taken  place  in  that  time.  One  must  wait  at 
least  two  to  three,  and  usually  four  hours,  according  to  the  state  of 
the  food,  or  at  times  upon  the  condition  of  the  organ,  till  all  the 
ingredients  are  digested  sufficiently  to  pass  through  the  tube ;  and 
as  the  fluid  portions  of  the  food  are  absorbed  much  more  rapidly 
than  the  sohds,  the  contents  of  the  stomach  after  a  time  become 
more  and  more  hke  mush,  so  that  it  may  easily  happen  that  at  this 
time  a  sufficient  quantity  of  the  stomach  contents  can  not  be  ob- 


*  Kleraperer.  Ueber  die  Anwendung  der  Milch  zur  Diagnostik  der  Magen- 
krankheiten.     Charite-Annalen,  Bd.  xiv. 

f  [The  normal  amount  withdrawn  one  hour  after  a  test  breakfast  is  between  20 
to  60  c.  c.  [  I  |-ij] ;  quantities  much  greater  than  this  are  pathological. — Ed.] 


THE   TEST   MEALS.  03 

tained.  The  longer  period  of  waiting  is  of  less  importance,  since, 
after  all,  we  are  looking  for  comparative  results,  provided  the  larger 
meals  wonld  yield  more  information  abont  the  nature  and  course  of 
digestion  in  pathological  conditions ;  but  this  is  not  the  case.  Ein- 
horn,*  Jiirgensen,f  Loewenthal,:j:  and  many  other  writers,  have 
shown  that  in  both  methods  the  variations  in  the  results  were  only 
differences  in  the  absolute  values,  but  neither  had  any  special  pathog- 
nostic  advantages.  It  is  undoubtedly  true  that  inspection  of  the 
stomach  contents  obtained  after  a  mixed  diet  will  at  a  glance  show 
the  degree  of  digestion  of  the  starches  and  albuminoids,  and  espe- 
cially of  the  meat ;  yet  the  digestive  capacity  may  also  be  de- 
termined by  the  changes  in  the  roll,  and  whenever  it  is  necessary 
we  can  always  supplement  it  with  the  test  dinner.  A  gastric  juice 
which  digests  a  roll  completely  will  also  digest  meat ;  while,  on  the 
other  hand,  any  increase  in  the  secretion  (hypersecretion  and  hyper- 
chlorhydria)  may  be  detected  with  the  simple  digestive  stimuh  as 
well  as  with  the  more  complicated  one.  The  gastric  juice  which 
can  not  digest  a  roll  will  be  still  more  insufficient  when  mixed  diet 
or  meat  is  taken. 

On  the  other  hand,  the  test  breakfast  possesses  the  great  advan- 
tage that  we  can  at  once  detect  old  food  remnants,  such  as  fragments 
of  meat,  vegetables,  etc.,  which  have  remained  in  the  stomach. 
Thus  there  are  many  ])ros  and  cons  for  both  methods,  and  while  it 
must  be  admitted  that  the  test  breakfast  is  practically  the  most  use- 
ful, yet  we  can  succeed  with  any  meal  which  is  known  to  stimulate 
the  normal  stomach  sufficiently.  However,  the  advantages  of  the 
test  breakfast  are  so  great  that  I  usually  confine  myself  to  it.  It  is 
especially  convenient  where  large  numbers  of  examinations  must  be 
made,  and  hardly  anything  else  could  be  used  in  consultation  prac- 
tice, where  the  patient's  general  condition  is  determined  on  one 
day,  and  early  on  the  following  morning  he  may  come  for  the  ex- 


*  Einhom.     Probefruhsfciick  oder  Probemittagbrod?     Berl.  klin.  "Wochenschrift, 
1888,  No.  32. 

f  Chr.    Jilrgensen.      Probemittagmahlzeit   oder    Probef rulistilek  ?     Berl.   klin. 
Wochenschrift,  1889,  No.  20. 

X  M.  Loewenthal.     Beitrage  ziir  Diagnostik  und  Therapie  der  Magenkrankhei- 
ten.     Inaug.  Dissertation,  Berlin,  1892. 
3 


24  DISEASES  OP  THE  STOMACH. 

aniination  of  the  stomacli,  and  thus  the  inconveniences  of  the  pro- 
cedure are  reduced  to  a  minimum.* 

Examination  of  Stomach  Contents. — The  filtrate  of  the  stomach 
contents  which  is  obtained  from  the  test  breakfast  when  digestion 
is  normal,  is  a  clear  watery  or  light  to  brownish-yellow  fluid,  which 
may  readily  be  used  for  all  the  various  chemical  procedures.  Upon 
the  filter  is  left  a  mushy  mass  consisting  of  fine  particles  of  the 
digested  roll,  and  scarcely  any  mucus ;  it  should  not  contain  any 
admixtures,  such  as  old  food  fragments  or  blood.  At  times,  when 
bile  has  regurgitated  into  the  stomach,  the  chyme  may  assume  a 
light-greenish  color  on  standing.  If  the  filtrate  contains  either  the 
normal  or  an  excessive  amount  of  hydrochloric  acid,  it  will  remain 
as  clear  as  water  for  days,  and  during  the  first  few  days  will  scarcely 
undergo  any  change  in  its  acidity ;  but  when  the  amount  of  hydro- 
chloric acid  is  subnormal  it  soon  becomes  turbid  and  moldy. 

Under  ordinary  conditions  secretion  ceases  as  soon  as  the  chyme 
has  passed  into  the  intestines.  The  evacuation  of  the  stomach  may 
at  times  be  delayed,  and  hence  the  period  of  secretion  may  be  pro- 
longed. This  condition,  however,  must  be  differentiated  from  that 
of  the  continuous  secretion  of  gastric  juice,  since,  during  the  latter, 
secretion  goes  on  even  when  the  stomach  is  empty.  Yarious  names 
have  been  applied  to  this  condition :  gasi/PosucGorrhma  {Magensaft- 
fluss)  by  Eeichmann,  hypersecretio  acida  continua  by  Jaworski, 
acute  and  chronic  continuous  secretion  of  gastric  juice  by  Eiegel, 
while  I,  for  the  sake  of  brevity,  simply  called  it  parasecretion  [see 
Chapter  XI].  This  classification  is  thus  based  upon  the  time,  and 
not  the  quantity,  of  the  secretion.  Hence  secretion  must  not  be 
confounded  with  acidity ;  the  latter  may  be  normal,  increased  (su- 
peracidity),  diminished  (subacidity),  or  absent  (anacidity).  Further- 
more, the  acidity  must  be  distinguished  from  the  percentage  of 
hydrochloric  acid,  which,  as  we  shall  see  later  on,  may  vary  from 
an  excess  {hyperchlorhydria)  to  an  absence  of  hydrochloric  acid 
{achlorhydria). 

Determination  of  Acidity. — The  first  thing  which  must  be  deter- 

*  [It  is  not  advisable  to  depend  upon  the  results  of  one  examination  ; 
to  be  at  all  certain,  at  least  three  test  meals  should  be  given  at  different 
times. — Ed.] 


DETERMIXATION  OP  ACIDITY.  25 

mined,  in  normal  stomach  contents  wliicli  have  been  removed  at  the 
height  of  digestion  is  the  acid  reaction ;  this  is  due  for  the  most  part 
to  the  secreted  HCl,  the  balance  to  other  factors,  the  most  important 
of  which  are  the  acid  salts  which  are  found  in  the  stomach  contents. 
At  this  time  the  acidity  is  highest ;  from  the  beginning  of  digestion 
it  gradually  increases  up  to  this  point,  and  then  gradually  dimin- 
ishes. The  secretion  of  HCl  begins  at  the  moment  when  the  glan- 
dular cells  are  stimulated  to  activity  by  the  ingested  food  ;  it  at  once 
combines  with  the  bases  which  may  be  present,  and  forms  inorganic 
and  organic  salts.  These  are  neutral  salts  (chlorides),  HCl-albu- 
minates ;  later  on  HCl-albumoses  and  pej)tones  also  are  formed. 
Although  the  combinations  of  HCl  and  albuminoids  have  an  acid 
reaction — i.  e.,  redden  litmus — yet  the  HCl  present  in  them  has 
been  deprived  of  its  character  of  a  free  acid,  and  hence  the  tests  for 
free  HCl  (which  will  be  described  later  on)  are  negative.  These 
HCl  combinations,  however,  are  not  very  stable,  since  even  satura- 
tion with  calcic  carbonate  at  ordinary  temperature  will  decompose 
them,  and  naturally  they  are  destroyed  by  combustion.  We  may 
therefore  correctly  designate  this  portion  the  loosely  combined  HCl. 
According  to  the  quantity  and  quality  of  its  food,  these  bases 
which  combine  with  HCl  are  saturated  sooner  or  later,  and  thus, 
since  the  activity  of  the  glands  still  continues, /"r^e  HCl^  appears  in 
the  stomach,  the  quantity  of  which  increases  until  it  reaches  its  maxi- 
mum at  the  height  of  digestion^  and  then  diminishes  ;  but,  as  far  as 
our  present  knowledge  will  allow  us  to  judge,  it  persists  and  can 
always  be  demonstrated  until  the  stomach  is  completely  evacuated. 
To  put  it  in  other  words,  we  may  say  that  at  the  height  of  digestion 
the  chlorine  is  present  in  the  following  combinations  : 

*  Recently  the  free  HCl  has  been  designated  as  "excessive"  (ueberschussig).  It 
seems  to  me  that  this  term  has  been  poorly  chosen,  since  this  would  indicate  that 
the  combined  HCl  was  the  chief  factor  in  the  physiological  process  of  digestion, 
although  it  is  undoubtedly  true  that  the  free  HCl  plays  an  equally  important  part  in 
the  peptic  and  antifermentative  actions  of  the  gastric  juice.  Furthermore,  the  term 
free  HCl  has  been  generally  adopted  by  physicians,  and  has  been  accepted  in  the 
sense  I  have  defined  above.  At  all  events,  chemically  speaking,  the  loosely  com- 
bined and  the  free  HCl — i.  e.,  the  total  chlorine  compounds,  with  the  exception  of 
the  chlorides  (the  ammonia  may  be  disregarded) — may  be  designated  free  HCl ; 
but  it  would  only  complicate  matters  and  would  give  rise  to  many  errors  if  this 
nomenclature  were  employed  and  recommended  for  general  use,  as  has  been  urged 
by  Leo. 


26  DISEASES  OF  THE   STOMACH. 

1.  With  hydrogen,  as  free  HCL 

2.  Combined  with  organic  substances,  as  loosely  combined  HCL 

3.  Combined  with  inorganic  bases,  as  chlorides,  which  have  either 
been  introduced  with  the  food  or  have  been  formed  in  the  stomach. 

Inasmuch  as  in  the  various  test  meals,  and  esj)ecially  in  the  test 
breakfast,  only  small  and  fairly  uniform  quantities  of  inorganic 
chlorides  or  bases  and  salts  from  which  chlorides  might  be  formed 
in  the  stomach  are  introduced  [i.  e.  3],  it  is  evident  that  the  esti- 
mation of  the  chlorine  contained  in  them  is  of  no  importance  in 
studying  the  processes  of  gastric  secretion. 

Accordingly,  the  general  course  of  the  secretion  of  HCl  may  be 
represented  by  a  curve  which  begins  at  zero,  rises  to  a  maximum, 
and  then  descends.  The  hrst  period,  which  is  a  small  one,  including 
the  formation  of  chlorides  and  the  loosely  combined  HCl,  is  that 
which  extends  from  the  beginning  of  digestion  to  the  occurrence  of 
free  HCl ;  the  second  and  larger  period  is  that  of  digestion  with 
combined  and  free  HCl.  The  maximum  secretion  of  HCl  occurs 
in  the  second  period,  and  varies  as  to  time  and  amount,  according 
to  the  food  and  the  digestive  power  of  the  individual.  On  a  frugal 
diet  (test  breakfast)  this  is  at  the  beginning  of  the  second  hour  ;  the 
amount  of  free  HCl  varies  approximately  between  1-5  and  2-0  per 
mille  ;  on  an  abundant  mixed  diet  this  occurs  later,  as,  for  example, 
in  Riegel's  test  meal,*  in  the  third  to  fourth  hour,  with  values 
of  2"3  to  3-0  per  mille.  However,  it  is  natural  that  these  figures 
are  only  approximate  and  not  absolutely  fixed,  and  that  in  each 
individual  patient  the  general  characteristics  of  the  case  must  be 
considered  in  drawing  conclusions  from  these  extreme  figures. 
However,  results  which  are  much  below  or  above  them  may  at  once 
be  considered  pathological. 

Putting,  then,  the  various  possible  quantitative  changes  in  the 
secretion  of  HCl  in  an  ascending  scale,  we  would  have  : 

1.  Achlorhydria.f 

*  [Riegel's  test  meal  consists  of  a  plate  of  soup,  150  to  200  grammes  (5-6^  oz.) 
of  beefsteak,  50  grammes  (If  oz.)  mashed  potatoes,  and  a  roll.  It  is  evacuated  after 
three  to  four  hours.  Its  advantage  is  that  the  relative  digestion  of  the  starches 
and  albuminoids  can  be  determined  at  a  glance ;  its  disadvantage  resides  in  the 
plugging  of  the  tube  by  large  fragments  of  meat. — Ed.] 

f  Some  authors,  for  the  sake  of  euphony,  speak  of  anachlorhydria — e.  g.,  Lyon, 


DETERMINATION    OP  ACIDITY. 


27 


2.  Plypoclilorhydria. 

3.  Euclilorliydria. 

4.  Hyperchlorhydria. 

The  curve  in  tlie  accompanying  figure  (Fig.  4)  may  be  taken  as 
an  example  of  tlie  course  of  the  secretion  of  HCl ;  it  was  constructed 
from  a  patient  with  a  gastric  fistula,  from  whom  the  stomach  con- 
tents were  taken  at  first  every  ten  minutes,  and  later  every  half  hour. 
Free  HCl  first  ap- 
peared at  the  point 
marked  with  a  *. 

Although  the 
greater  portion  of 
the  acidity  of  the 
stomach  contents  is 
due  to  HCl,  yet  the 
acid  salts,  especially 
the  acid  phosphates 
(sodic  and  potassic 
phosphates),  which 
are  introduced  in 
variable  amounts 
with  the  food,  also 
participate  in  it,  al- 
though to  a  lesser 
degree.  As  a  rule, 
they  are  unimportant  as  compared  to  free  HCl,  and  their  significance 
has  never  been  exaggerated  by  German  writers,  as  stated  by  Hay  em 
and  Winter ;  yet  it  would  be  a  gross  error  to  simply  disregard  them 
in  calculating  the  acidity. 

The  presence  of  small  quantities  of  lactic  acid  in  the  beginning 
of  digestion  is  an  entirely  different  matter.  Small  quantities  of 
lactic  acid  may  frequently  be  found  at  this  time,  when  the  lactic 
acid  bacilh  which  have  been  introduced  with  the  food  have  had  an 


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MlhUTES 

¥iG.  4. — Curve  showing  the  course  of  the  secretion  of  HCl 
after  a  test  breakfast.  The  cross  indicates  the  time  at 
which  free  HCl  tirst  appeared. 


L'analyse  de  sac  gastrique ;  the  grammatical  term  is  that  given  above.  [I  have 
retained  throughout  this  work  the  term  chlorhydria — i.  e.,  amount  of  HCl— on  ac- 
count of  the  convenience  of  its  compounds  in  expressing  in  one  word  the  differences 
in  amount  of  HCl. — Ed.] 


28  DISEASES  OP  THE  STOMACH. 

opportunity  to  thrive.  This  may  occur  only  in  the  early  periods  of 
digestion,  as  long  as  large  quantities  of  HCl  have  not  been  secreted ; 
for  the  conversion  of  starch  into  sugar,  which  is  essential  for  their 
activity  ceases  as  soon  as  there  is  0'3  per  mille  HCL*  The  forma- 
tion of  lactic  acid  itself  ceases,  according  to  Cohn,f  and  also  Hirsch- 
feld,:j:  when  the  amount  of  HCl  is  0*7  per  mille  ;  according  to  the 
latter  it  is  markedly  lessened  when  the  HCl  is  between  O"!  and  0-2 
per  mille.  Hence  in  a  normal  stomach  this  can  take  place  only  a 
short  time.  In  a  large  number  of  investigations  made  long  ago  by 
Boas  and  myself,*  we  found  lactic  acid  so  regularly  at  the  begin- 
ning of  digestion,  that  we  believed  its  presence  to  be  a  constant 
factor,  and  accordingly  described  three  stages  in  the  digestion  of 
the  test  breakfast :  the  first  with  lactic  acid ;  the  second  or  inter- 
mediate stage  with  lactic  acid  and  small  quantities  of  free  HCl ; 
the  third,  which  occurred  toward  the  end  of  the  first  hour  and 
when  digestion  was  at  its  height,  with  only  free  HCL 

l^evertheless,  we  have  always  considered  the  formation  of  lactic 
acid  an  accidental  factor  which  is  dependent  upon  the  introduction 
into  the  stomach  of  carbohydrates,  especially  sugar,  and  the  lactic 
acid  bacilli,  although  the  latter  may  have  already  been  present  in 
the  gastric  mucus  ;  for  if  a  roll  or  bread  is  broken  up  in  water  and 
kept  for  a  time  at  the  bodily  temperature  no  lactic  acid  is  normally 
detected.!!  ]^either  did  we  assume,  as  claimed  by  Martins  and 
Luttke,"^  that  HCl  is  derived  from  lactic  acid.  On  the  contrary,  we 
have  shown  that  no  lactic  acid  is  normally  formed  when  pure  albu- 
min has  been  eaten  ;  ^  yet  my  present  experience  convinces  me  that 
we  had  gone  too  far  in  assuming  that  the  formation  of  lactic  acid 
was  always  the  rule  after  eating  bread,  and  hence  also  a  factor  in  its 

*  Ewald.  Ueber  Znckerbilduiig  im  Magen  und  Dyspepsia  acida.  Berl.  klin- 
Wochensch.,  1886,  No.  48. 

f  P.  Cohn.  Ueber  die  Einwirkung  der  kiinstlichen  Magensaf tes  auf  Essigsaiire. 
und  Milehsauregahrung.     Zeitschr.  fiir  phys.  Chera.,  Bd.  xiv,  p.  75. 

1^.  E.  Hirsehfeld.  Ueber  die  Einwirkung  der  kiinstlichen  Magensaftes  auf  Essig- 
saure-  und  Milehsauregahrung.     Pfliiger's  Arch.,  Bd.  xlvii,  p.  5G0. 

*  Virchow's  Arch.,  Bd.  civ,  p.  271. 

II  Ewald.    Ueber  Zuckerbildung  im  Magen,  etc.,  loc.  cit. 

^  Martins  und  Lilttke.     Die  Magensaure  des  Menschen,  1892,  p.  24. 

()  "  If  food  be  given  which  contains  nothing  from  which  lactic  acid  may  be  pro- 
duced, such  as  pure  egg  albumin,  only  free  HCl  will  be  found."  Ewald.  Klinil:, 
etc.,  I.  Theil,  3te  Aufiage,  p.  86. 


LACTIC  ACID.  29 

peptonization.  Althougli  the  presence  of  lactic  acid  was  proved  by 
the  formation  of  lactates,  and  was  also  confirmed  by  all  subsequent 
writers — Calm  and  von  Mering,*  Ritter  and  Hirsch,f  Rosenheim, ;]; 
Leo,*  Stintzing,  ||  and  von  Jaksch,^  to  mention  only  the  German 
writers — and  although  some  of  these  writers  have  even  traced  the 
lactic  acid  to  the  end  of  digestion,  yet  I  have  repeatedly  seen  cases 
in  which  this  acid  was  entirely  absent  throughout  the  entire  course 
of  digestion.  That  Martins  and  Liittke  ()  should  have  reached  the 
same  conclusion  did  not  therefore  surprise  me ;  careful  investiga- 
tions with  their  method  (see  page  51)  showed  that  the  acidity  had 
coincided  with  that  of  HCl,  and  that,  so  to  speak,  there  was  no  room 
for  any  lactic  acid.  But  I  have  laid  no  undue  weight  upon  this  fact, 
which,  as  stated,  was  long  known  to  me;  first,  because,  in  view  of 
what  I  have  already  explained,  it  was  by  no  means  striking ;  sec- 
ondly, because  it  is  by  no  means  a  constant  factor  ;  and,  thirdly,  and 
most  important  for  practical  purposes,  lactic  acid  is  normally  always 
absent  at  the  height  of  digestion.  It  is  this  relation  to  the  typical 
course  of  HCl  secretion  which  is  of  clinical  value,  and  changes  in 
which  may  indicate  pathological  conditions.  This  fact  is  by  no 
means  altered  because  several  of  the  above  writers  could  with  com- 
plicated and  dehcate  tests  demonstrate  traces  of  lactic  acid  even  at 
a  late  stage  of  digestion.;^  This  can  not  be  done  in  the  ordinary 
lactic-acid  tests,  such  as  Uffelmann's  (see  page  41),  which  are  not 
so  delicate.  But  in  this  lack  of  sensitiveness  lies  the  value  of  this 
test.  For  we  have  no  method  by  which  an  excess  of  lactic  acid 
could  be  quickly  estimated ;  hence  the  value  of  a  reaction  which, 
as  in  the  case  here,  only  becomes  evident  when  there  is  a  patho- 
logical increase  of  lactic  acid  in  the  stage  of  digestion  under  dis- 

*  Cahn  und  v.  Mering.  Ueber  die  Sauren  des  gesunden  und  kranken  Magens. 
Deutsch.  Archiv  f.  klin.  Med.,  Bd.  xxxix,  Hefte  3  u.  4. 

f  Ritter  und  Hirsch.  Ueber  die  Sauren  des  Magensaftes.  Zeitschr.  fiir  klin, 
Med.,  Bd.  xiii,  p.  446. 

X  Rosenheim.  Ueber  Magensaure  bei  Amylaceenkost.  Virchow's  Archiv,  Bd. 
cxi,  S.  414. 

*  Leo.    Diagnostik  der  Krankheiten  der  Verdauungsorgane,  1890. 

II  Stintzing.     Ueber  den  gegenwartigen  Stand  der  Diagnostik  der  Magenkrank- 
heiten.     Mlinch.  Wochenschr.,  1889,  ISTos.  8  and  9. 
^  Jaksch.     Klinische  Diagnostik,  3te  Aufl.,  1893. 
(}  Martins  und  Liittke.     Loc.  cii.,  pp.  13  and  156. 
$  I  have  corroborated  this  in  several  cases.    See  first  edition  of  this  work,  p.  31. 


30  DISEASES  OP   THE  STOMACH. 

cussion.  I  am  therefore  justified  in  maintaining  the  value  of  this 
procedure  in  spite  of  the  objections  raised  by  Martins  and  Liittke.* 

[During  the  past  few  years  much  has  been  written  f  on  the  sub- 
ject of  the  relations  of  lactic  acid,  especially  since  Boas  claimed  a 
diagnostic  significance  for  the  presence  of  large  quantities  of  this 
acid  in  cancer  of  the  stomach. 

By  using  new  methods  (vide  infra)  for  detecting  lactic  acid, 
Boas  found  that  lactic  acid  is  not  produced  during  any  stage  of  di- 
gestion, and  that  bread  and  all  the  substances  which  are  usually 
given  in  test  meals  contain  lactic  acid  or  lactates  ;  he  therefore  pro- 
posed that  in  all  tests  for  lactic  acid  the  test  meal  given  should  con- 
sist of  an  oatmeal  soup  or  gruel,  which  is  made  by  boiling  a  table- 
spoonful  of  oatmeal  flour  with  a  quart  of  water,  the  only  addition 
being  a  little  salt.  The  stomach  contents  obtained  after  this  gruel 
contain  no  lactic  acid.  On  this  point,  however,  Boas  has  gone  too 
far ;  for  it  has  been  shown  by  many  observers  that  the  amount  of 
lactic  acid  or  lactates  iu  the  roll  of  a  test  breakfast  is  so  insignifi- 
cant that  it  may  practically  be  discarded,  since,  as  he  himself  ad- 
mits, in  all  cases  in  which  lactic  acid  has  any  significance  it  must  be 
present  in  such  large  quantities  that  Uffelmann's  test  will  give  us 
sufficiently  reliable  results.] 

The  practical  outcome  of  these  considerations  is,  that  the  simple 
fact  that  the  stomach  contents  are  acid  does  not  indicate  upon  what 
the  acidity  depends.  It  is  simply  a  sum  total  which  must  be  re- 
solved into  several  factors,  in  doing  which  we  must  always  remem- 
ber that  the  height  of  the  acidity  does  not  necessarily  coincide  with 
the  height  of  the  secretion  of  HCl,  and  that  secretion,  acidity, 
and  chlorhydria  must  be  carefully  distinguished  from  one  another. 
Furthermore,  under  pathological  conditions,  the  acidity  is  also  de- 
pendent upon  the  products  of  fermentation  of  the  carbohydrates 
and  fats — i.  e.,  lactic,  acetic,  and  butyric  acids,  and  even  alcohol. 
ISTevertheless  it  is  always  important  to  ascertain  how  acid  the  stom- 
ach contents  are — i.  e.,  to  test  the  acidity  with  volumetric  solutions 
and  the  hurette  (titration). 

*  Log.  cit.,  p.  56. 

f  [The  full  literature  on  this  subject  may  be  found  in  elaborate .  papers  by 
Langguth,  Boas'  Archiv,  Bd.  i,  p.  355,  and  De  Jong,  ibid.,  Bd.  ii,  p.  53.    Also  see 


THE  TESTS  FOR  TOTAL  ACIDITY.  31 

Tests  for  Total  Acidity. — This  is  ascertained  by  adding  to  the 
stomach  contents  a  sufficient  quantity  of  an  alkahne  solution  of 
definite  composition  which  will  neutralize  all  the  acid  contained 
in  them. 

The  question  a'c  once  arises  whether  we  should  em-ploy  filtered  stomach 
coutents,  as  has  been  done  heretofore,  or  whether  we  should  follow  the  sug- 
gestion of  Martins  and  Lllttke  to  use  them  unfiltered.  It  is  self-evideut 
that  different  results  will  be  obtained  according  as  we  make  use  of  the  one 
oi  the  other.  But  the  above-mentioned  writers  have  neglected  one  very 
imxjortant  fact,  that  in  either  case  absolute  values  are  never  obtained,  but 
only  relative  ones.  Absolute  values  are  never  obtained,  because  in  deter- 
mining the  acidity  by  titration  very  different  results  are  found  with  the 
various  indicators  employed  ;  and  we  must  never  forget  that  in  all  these 
procedures  we  are  dealing  with  certain  signs  whose  natru'e  and  useful- 
ness consist  in  the  fact  that  they  may  be  compared  with  one  another. 
In  measuring  unfiltered  stomach  contents  the  results  will  vary  with 
the  quantity  of  larger  or  smaller  fragments  of  food  contained  in  them, 
and  the  titrimetric  error  will  be  much  greater  because  the  unfiltered  stom- 
ach contents  must  be  strongly  diluted  in  order  that  they  may  be  used  for 
titration.  Experiments  with  such  a  complex  mixture  as  the  stomach  con- 
tents differ  rachcally  from  those  with  pm-e  solutions.  The  fact  that  we 
estimate  all  results  by  percentage  instead  of  by  absolute  values  has  this 
advantage,  that  it  suffices  to  determine  the  proportional  values.  It  is  self- 
evident  that  in  the  unliquefied  fragments  of  food  a  certain  amount  of  HCl 
has  been  imbibed,  the  absolute  amount  of  which  may  be  determined  if  we 
use  unfiltered  stomach  contents.  But  inasmuch  as  the  course  of  digestion 
is  such  that  a  corresponding  amount  of  HCl  is  also  in  solution  (free,  or 
combined  with  the  dissolved  albumin),  then  the  estimation  of  the  latter 
will  also  give  us  indications  of  the  amount  of  the  former ;  in  other  words, 
the  amount  of  work  accomplished  by  the  stomach.  And  that  is  the  very 
thing  which  we  wish  to  ascertain.  But  since  it  is  much  easier  and  more 
convenient  to  use  filtered  stomach  contents,  and  since  filtration  at  the 
same  time  also  offers  certain  other  diagnostic  data,  I  believe  that  I  am 
justified  in  adhering  to  the  old  method  of  studying  the  chemical  changes 
with  filtered  chyme. 

The  same  is  true  of  the  suggestion  of  Geigel  and  Blass  * — to  discuss 
this  point  at  the  same  time — that  we  should  estimate  the  total  quantity  of 
acid  which  is  present  in  the  stomach  at  that  particular  period  in  order  that 
we  may  use  this  as  a  means  of  estimating  the  functional  activity  of  the 
organ.     Concerning  this  I  would  say  the  following  : 

The  advantage  of  percentage  estimations  is  this,  that  they  give  us  re- 
sults which  are  independent  of  the  total  quantity  and  which  may  be  used 

Friedenwald.     IST.  Y.  Medical  Journal,  March  23,  1895 ;   and  Stewart.     Medical 
News,  February  16,  1895.— Ed.] 

*  G.eigel  und  Blass.  Procentuale  und  absolute  Aciditiit  des  Magensaftes.  Zeit- 
sehr.  fiir  klin.  Med.,  Bd.  xx,  Heft  3.  Geigel  und  Abend.  Die  Salzsaureseeretion 
bei  Dyspepsia  nervosa.    Virchow's  Archiv,  Bd.  cxxx,  Heft  1. 


32  DISEASES  OP  THE  STOMACH. 

in  comparing  different  cases.  In  order  to  draw  general  conclusions  from 
a  number  of  details— and  it  is  our  task  to  deduce  general  laws  from  the 
mass  of  confusing  details— it  is  of  no  value  to  know  in  each  individual 
case  the  total  amount  of  secretion,  which  varies  every  minute  ;  on  the  con- 
trary, it  is  much  more  important  to  know  the  relation  of  the  case  in  point 
to  some  absolutely  fixed  standard  of  comparison.  If  the  grade  of  a  street 
or  railroad  is  15  per  cent,  the  relation  to  all  other  roads  is  known,  no  mat- 
ter what  the  absolute  length,  elevation  above  the  sea.  level,  etc.,  may  be. 

The  results  of  the  very  numerous  examinations  which  have  been  made 
in  the  past  have  convinced  me  that  percentage  values  remain  uniform 
when  the  conditions  are  unchanged,  or,  to  put  it  in  other  words,  they 
change  in  a  corresponding  manner.  They  may  therefore  be  employed  in 
estimating  the  functional  powers  of  the  stomach.  A  priori,  it  is  evident 
that  the  percentage  value  and  the  absolute  amount  of  the  secretion  neither 
can  nor  must  always  agree,  since  both  factors  are  entirely  differently  in- 
fluenced by  absorption,  transudation,  emptying  of  the  stomach,  etc.  Nat- 
urally the  absolute  amount  of  HCl  will  vary  with  the  quantity  of  the 
chyme ;  and  also,  as  I  have  shown  elsewhere,*  it  may  happen  that  the 
percentage  will  remain  uniform  while  the  total  amount  of  HCl  will 
vary  from  minute  to  minute  on  account  of  the  evacuation  of  large  quan- 
tities of  chyme  into  the  intestines.  Hence  from  moment  to  moment  dur- 
ing the  course  of  digestion  varying  absolute  values  would  be  obtained 
which  bear  no  direct  or  absolute  relation  to  the  total  quantity  secreted  by 
the  mucous  membrane.  Consequently  the  determination  of  normal  and 
pathological  conditions  would  be  made  much  more  difficult,  instead  of 
being  simplified.  Our  knowledge  of  gastric  disorders  has  been  much 
advanced,  and  is  dependent  upon  the  estimations  by  percentages ;  while 
on  the  other  hand,  so  far  as  I  know,  no  new  diagnostic  facts  have  been 
gained  by  the  other  method.  It  is  therefore  advisable  to  adhere  to  the 
old  procedures,  and  the  more  so  because  the  method  of  Geigel  and  Blass 
is  so  complicated  as  to  be  useless  for  practical  purposes.  However,  it  is 
not  denied  that  it  may  be  of  some  interest  to  know  the  absolute  amount 
of  secretion  at  any  given  moment. 

[These  remarks  may  also  be  applied  to  the  various  methods  f 
which  have  been  suggested  to  determine  the  absolute  quantity  of 
stomach  contents  at  the  time  of  their  withdrawal.  These  proce- 
dures are  all  too  complicated  for  clinical  use,  nor  are  the  practical 
results  obtained  worth  the  trouble.] 

Titration  :j:  is  most  conveniently  performed  with  a  deci-normal 
solution  of  caustic  soda,  the  end  reaction  being  determined  with 
phenol-phthalein.     Should  the  reaction  of  the  stomach  contents  be 

*  Ewald.    Zeitschr.  fiir  klin.  Med.,  Bd.  xx,  Heft  4r-Q. 

f  [They  are  described  in  Boas,  loc.  cit.,  Bd.  i,  p.  139.  Riegel.  Erkrankungen  des 
Magens.     Nothnagel's  Encyclopiedia,  1896,  Bd.  xvi,  II.  Theil,  p.  88.— Ed.] 

X  [The  description  of  the  technique  of  titration  and  other  strictly  chemical  pro- 
cedures lies  beyond  the  province  of  this  work.     Those  who  desire  further  informa- 


THE   TESTS  FOR  TOTAL  ACIDITY.  33 

alkaline,  the  degree  of  alkalinity  may  be  determined  with  a  deci-nor- 
mal  acid  solution.  ISTormal  caustic  soda  solution  contains  40  grm.  to 
the  litre,  so  that  1  c.  c.  deci-normal  caustic  soda  solution  is  equivalent 
to  0-003646  grm.  HCl  or  0-009  grm.  lactic  acid.  Phenol-phthalein,  a 
derivative  of  benzol,  is  a  buff-colored  powder,  freely  soluble  in 
alcohol,  making  a  slightly  opalescent  solution,  which  remains  color- 
less in  acid  or  neutral  solutions,  but  assumes  a  carmine  color  in  alka- 
line solutions.  The  procedure  is  simple :  a  Mohr's  burette  *  is 
filled  with  the  deci-normal  solution  of  caustic  soda ;  5  or  10  c.  c.  of 
the  filtered  stomach  contents  are  poured  into  a  small  glass  beaker, 
and  one  or  two  drops  of  the  [one  per  cent]  alcoholic  solution  of 
phenol-phthalein  are  added.  The  solution  in  the  burette  is  very 
gradually  added  till  the  red  color  which  appears  in  the  contents  of 
the  beaker  no  longer  disappears  on  shaking,  but  remains  perma- 
nently. This  indicates  the  moment  when  all  the  acids  are  saturated 
or  neutralized,  or,  to  put  it  more  exactly,  it  denotes  that  the  reaction 
has  just  turned  alkahne.  The  number  of  cubic  centimetres  of  the 
solution  in  the  burette  which  have  been  used  represents  the  acidity 
of  the  quantity  of  stomach  contents  which  have  been  employed.  A 
slight  turbidity  or  yellowish  color  of  the  stomach  contents  does  not 
interfere  with  the  dehcacy  of  the  reaction ;  it  is  also  to  be  noted 
that  the  addition  of  the  phenol-phthalein  gives  a  slightly  milky 
appearance  to  many  stomach  contents,  f     As  a  rule,  the  acidity  of 

tion  than  is  given  in  the  text  will  And  these  methods  fully  described  in  the  Hand- 
book of  Volumetric  Analysis,  by  Edward  Hart;  New  York,  John  Wiley  &  Sons. 
In  all  these  volumetric  methods  the  metric  system  is  obviously  alone  employed. 
—Ed.] 

*  Where  titrations  are  not  made  daily,  Kleinert's  burette  will  be  found  very  con- 
venient. This  burette  differs  from  the  ordinary  form  with  glass  stopcock  in  hav- 
ing the  latter  at  the  upper  end  above  the  zero  mark  of  the  scale,  while  the  lower 
end  is  somewhat  drawn  out,  and  is  ground,  to  permit  its  being  closed  with  a  glass 
cover.  The  burette  is  filled  by  dipping  the  lower  end  into  the  standard  solution  to 
be  used  and  sucking  at  the  upper  end  while  the  stopcock  is  open.  By  closing  the 
latter  the  atmospheric  pressure  will  keep  the  column  of  fluid  in  the  burette.  To 
titrate,  we  simply  turn  the  stopcock  above  instead  of  below,  as  usual.  After  use, 
the  lower  extremity  is  closed  with  the  well-greased  glass  cover.  In  this  way  we 
avoid  the  annoying  drying  of  the  stopcock,  and  also  the  alteration  due  to  exposure 
to  the  air  which  occurs  in  the  ordinary  form  in  the  drops  of  fluid  in  the  lower  end, 
if  the  burette  is  not  in  continual  use  ;  this  change  is  due  to  the  formation  of  car- 
bonates. 

f  In  the  test  I  have  only  described  titration  with  phenol-phthalein.  It  is  a  well- 
known  fact,  to  which  Lippmann  (Ueber  den  Sauregrad  des  Mageninhaltes  bei  An- 


34  DISEASES  OF   THE   STOMACH. 

10  c.  c.  of  stomach  contents  obtained  one  honr  after  the  test  break- 
fast ranges  between  4  to  5  or  5  to  6  c.  c. ;  results  above  or  below 
these  limits  are  pathological.  It  is  a  matter  of  convenience  to  ex- 
press the  acidity  in  percentage  according  to  the  amount  of  the  deci- 
normal  soda  solution  used ;  thus,  for  example,  61  per  cent  acidity 
would  mean  that  100  c.  c.  of  filtered  stomach  contents  were  neu- 
tralized by  61  c.  c.  of  a  deci-normal  soda  solution.  This  prevents 
any  misconception  that  the  acidity  depends  on  free  hydrochloric 
acid.  If  we  are  sure  that  the  acidity  depends  on  the  latter,  and  not 
on  salts  or  any  other  acids,  we  may  express  the  value  as  HCl.  Let 
us  take  an  example:  61  c.  c.  of  deci-normal  soda  solution  had  to 
be  added  to  10  c.  c.  of  stomach  contents  until  the  end  reaction  ap- 
peared. One  cubic  centimetre  deci-nqjrmal  soda  solution  being 
equivalent  to  0*00364:6  HCl,  when  10  c.  c.  of  stomach  contents  are 
used,  multiply  0-03646  by  the  number  of  cubic  centimetres  added 
from  the  burette  till  the  contents  of  the  beaker  are  neutralized ; 
this  will  give  the  percentage  of  HCl  in  the  stomach  contents  under 
examination.  Thus  in  the  example  the  actual  percentage  of  HCl  is 
0-22  per  cent ;  this  result  is  within  the  normal  limits  (0'14  to  0*24 
per  cent). 

To  determine  whether  the  acidity  depends  on  free  acids  or  acid 
salts,  the  aniline  dyes  will  be  found  the  most  useful ;  of  these  the 
best  is  TropcBolin  00 — V orange  Poirier  of  the  French.  This 
powder,  when  dry,  has  a  beautiful  orange  color ;  in  saturated  watery 
or  alcoholic  solutions  it  is  a  dark  yellowish  red  ;  in  the  presence  of 
traces  of  free  acid — even  as  little  as  about  0-25  per  thousand  [1  in 
4,000] — it  changes  to  dark  brown,  but  acid  salts  make  it  straw  yel- 
low. Take  a  small  quantity  of  the  reagent  and  add  a  few  drops  of 
dilute  HCl  (containing  about  O'OS  per  cent  pure  HCl) ;  the  solution 
at  once  assumes  a  deep  dark-brown  color.     If  some  acid  sodium 


wendung  verschiedener  Indicatoren.  Inaug.  Dissert.  Neuwied,  1891)  has  again 
directed  attention,  tliat  the  various  indicators,  rosolic  acid,  cochineal,  fluorescin, 
litmus,  curcuma,  etc.,  give  very  different  values  for  the  so-called  point  of  neu- 
tralization. Thus  the  acidity  of  a  specimen  of  stomach  contents  was  65-8  with 
phenol-phthalein,  54-6  with  rosolic  acid,  and  51-8  with  litmus.  An  interesting  dis- 
cussion of  this  subject  has  been  published  by  Spitzer  (Ueber  die  Benutzung  gewisser 
FarbstofEe  zur  Bestimmung  von  AfRnitaten.  Pfliiger's  Archiv,  Bd.  iv,  p.  551). 
Hence  it  is  necessary  to  always  employ  the  same  indicator. 


THE   TESTS  FOR  FREE   ACIDS.  35 

pLiosphate  is  added  to  the  tropseolin  solution,  the  color  turns  not 
brown,  but  a  light  straw  yellow.  When  free  acid  and  acid  salts  are 
both  present,  a  turbid,  dirty  brown  color  will  be  obtained  according 
to  which  of  these  predominates.  Thus  tropaeolin  enables  us  to  de- 
termine whether  free  acids  (hydrochloric  or  lactic)  are  present. 

The  dye  called  Congo  red,  which  was  introduced  by  Hoesslin,* 
has  a  similar  action  ;  its  solutions  assume  a  peach  to  a  brownish-red 
color.  The  addition  of  a  free  acid  changes  it  to  a  sky  blue.  It  is 
more  delicate  than  tropseolin,  and  will  react  to  a  fluid  containing 
but  0'02  per  thousand.     Acid  salts  produce  no  change. 

Methyl  violet  is  another  dye  which  may  be  mentioned ;  it  is  used 
in  an  aqueous  solution,  which  is  diluted  till  it  has  a  reddish-violet 
color.  The  addition  of  even  0*024  per  cent  of  HCl  to  the  solution 
changes  the  tint  to  a  sky  blue,  which  is  a  different  color  than  the 
original,  as  can  readily  be  determined  when  both  tubes,  before  and 
after  adding  the  stomach  contents,  are  held  up  to  the  light. 

In  these  tests,  as  well  as  in  all  the  other  reactions  to  be  mentioned 
later,  there  must  be  an  excess  of  the  fluid  to  be  tested  over  the  color 
solution,  otherwise  delicate  changes  might  escape  notice.  The 
best  method  is  to  pour  5  to  10  drops  of  the  color  solution  into  a 
small  test  tube  and  then  add  1  to  2  c.  c.  [15  to  30  drops]  of  the  fil- 
tered stomach  contents.  We  may  also  pour  a  little  of  the  dye  upon 
a  white  porcelain  capsule,  spread  it  out  in  a  thin  layer  by  shaking 
the  capsule  from  side  to  side,  and  then  add  a  few  drops  of  the  fil- 
trate at  the  edge  of  the  layer.  [The  color  reaction  will  then  be  seen 
at  the  place  of  contact.]  Or  we  may  dip  ordinary  filter  paper  into 
a  solution  of  the  dye.  allow  it  to  dry,  and  cut  it  uj)  into  narrow 
strips.  [A  strip  is  dipped  into  the  specimen  of  stomach  contents ; 
the  moistened  place  will  then  assmne  the  characteristic  color.  Such 
test  papers  may  be  also  prepared  with  many  of  the  dyes  to  be  men- 
tioned later  on.  This  is  the  most  convenient  way  of  employing 
these  tests.]  These  are  all  merely  modifications  of  the  same  thing. 
It  is  to  be  observed  that  the  test  papers  are  somewhat  less  delicate 
than  the  freshly  prepared  solutions,  and  they  become  even  less 
delicate  after  they  have  been  kept  for  some  time.     Thus  Boas  and 

*  Von  Hoesslin.     Ein  neues  Reagent  auf  freie  Sauren.     Miinch.  med.  "Wochen- 
schr.,  No,  6,  1886. 


36  DISEASES  OP  THE  STOMACH. 

myself  found  that  the  lower  limit  of  delicacy  of  Congo  paper  was 
0-1  per  mille,  which  is  ten  times  greater  than  that  of  the  solution  of 
the  dye.  The  delicacy  of  tropaeolin  paper  which  is  a  year  old  is 
much  diminished. 

The  delicacy  of  all  these  reactions  is  markedly  affected  by  the 
presence  of  salts  and  albuminoids,  especially  albumoses  and  pep- 
tones. Certain  salts,  as,  for  example,  sodium  chloride,  enter  into 
combinations  with  the  dyes  which  are  very  stable  even  though  they 
are  not  true  chemical  compounds,  and  not  even  the  addition  of 
small  quantities  of  acid  suffices  to  break  them  up  again ;  on  the 
other  hand,  albumen  and  its  derivatives  form  "unstable  combinations 
with  a  portion  of  the  free  acid,  and  thus  also  disturb  the  reaction. 
Yet,  at  all  events,  we  can  roughly  estimate  whether  we  are  dealing 
with  free  acid  or  acid  salts,  and  can  obtain  a  rough  idea  of  the 
amount  of  free  acid  by  the  intensity  of  the  reaction. 

For  example,  test  whether  the  specimen,  whose  acidity  is  61  per 
cent  (  =0-2  per  cent  HCl),  contains  free  acid.  First  add  some  to 
the  Congo  red  solution ;  it  assumes  a  pale-blue  color,  but  its  intensity 
is  much  less  than  this  control  test  with  a  0*2  per  cent  hydrochloric- 
acid  solution.  The  same  difference  is  observed  in  the  reactions  with 
tropseolin.  Therefore,  along  with  the  free  acid  which  is  present  in 
this  specimen  there  are  also  acid  salts. 

How  can  we  determine  the  nature  of  the  free  acids  ? 

For  the  Determination  of  Hydrochloric  Acid  the  above-mentioned 
dyes  are  of  little  use,  because  the  reaction  of  these  aniline  dyes 
toward  hydrochloric  acid  is  somewhat  uncertain,  since  they  are  de- 
colorized by  other  acids,  especially  the  organic ;  as  I  have  already 
shown,  their  delicacy  is  also  affected  by  other  substances.  Unfor- 
tunately, these  substances  are  the  ones  which  we  always  encounter 
in  the  stomach  contents  during  ordinary  digestion — i.  e.,  albumen 
and  its  derivatives,  saliva  (an  albuminous  and  saline  fluid),  chlorides, 
and  phosphates.  What  I  said  while  discussing  the  demonstration  of 
free  acid  is  also  true  here.  They  either  simulate  or  prevent  the 
change  of  color.  There  has  been  much  discussion  on  this  point, 
and  the  attempt  has  been  made  to  use  this  as  a  criterion  for  the  use- 
fulness of  the  various  reagents.  The  truth  is  that  they  all  react 
only  to  free  acid,  and  it  depends  upon  the  delicacy  of  the  various 


THE  TESTS  FOR  HYDROCHLORIC  ACID.  37 

reagents  toward  the  latter  whether  the  reaction  will  occur  in  the 
presence  of  a  definite  amount  of  albumen,  etc. ;  or,  in  other  words, 
whether  enough  free  acid  will  be  left  over  to  give  the  reaction 
after  all  the  compounds  have  been  formed  which  the  acid  may 
enter  into  in  such  a  mixture. 

Therefore,  in  making  comparative  tests  with  solutions  of  acids 
which  exceed  the  sensitiveness  of  a  reagent,  the  more  delicate  the 
reagent  the  greater  is  the  amount  of  the  above-named  substances 
[albumen,  etc.]  which  may  be  added  without  preventing  the  reac- 
tion ;  the  opposite  result  will  be  observed  if  we  are  working  with 
solutions  which  still  contain  even  a  trace  of  acid  to  act  upon  the 
reagent.  This  enables  us  to  understand  the  statement  made,  for  ex- 
ample, by  Seeman,*  that  a  combination  of  equal  parts  of  a  i-per- 
cent  peptone  solution  and  a  0-2-per-cent  HCl  mixture  will  just  give 
the  methyl- violet  reaction;  while  Krukenberg f  claims  that  the 
phloroglucin  reagent  (see  p.  38)  will  do  the  same  when  one  part  of 
a  4-per-cent  peptone  solution  is  added  to  two  parts  of  the  identical 
HCl  mixture.  It  simply  means  that  methyl-violet  is  about  f om' 
times  less  sensitive  than  phloroglucin -vanillin. 

As  early  as  1880  I  called  attention  to  this,:{:  and  showed,  espe- 
cially concerning  the  methyl-violet  reaction,  that  "  it  was  delayed  by 
the  presence  of  even  small  quantities  of  blood,  and  that  it  was 
markedly  enfeebled  or  even  prevented  by  solutions  of  hydrochlorate 
of  leucin  and  tyrosin  as  well  as  by  albumen  and  peptone."  The  or- 
ganic acids  which  have  been  alluded  to  above  as  affecting  the  color 
solutions  include  lactic  acid,  acetic  acid,  and  butyric  acid ;  yet,  in 
order  to  simulate  the  changes  produced  by  HCl,  much  stronger  solu- 
tions are  requisite  than  are  found  in  the  stomach  contents,* 

l^evertheless,  the  value  of  these  dyes  as  reagents  for  HCl  is  less- 

*  Seeman.  Ueber  das  Vorhandensein  freier  Salzsaure  im  Magen.  Zeitschr.  fiir 
klin.  Med.,  Bd.  v,  1882. 

f  Krukenberg.  Ueber  die  diagnostische  Bedeutung  des  Salzsaurenachweises  bei 
Magenkrebs.     Inaug.  Dissert.     Heidelberg,  1888. 

X  Ewald.  Ueber  das  angebliche  Fehlen  freier  Salzsaure  im  Magensaft.  Zeit* 
schr.  fiir  klin.  Med.,  Bd.  i,  S.  623. 

*  A  number  of  other  reagents  for  free  HCl,  like  Mohr's,  Reoch's,  Kahler's,  etc., 
have  also  been  published,  which  I  have  described  in  former  editions,  but  have  now 
omitted  because  they  have  only  a  historical  value.  Mohr  employed  the  reaction 
which  occurs  on  the  addition  of  free  HCl  to  a  10  per  cent  solution  of  sulpho- 


38  DISEASES   OP   THE  STOMACH. 

eued,  especially  since  the  reagents  proposed  by  Giinzbnrg*  and 
Boas  f  do  not  labor  under  these  disadvantages.  Both  methods  have 
therefore  been  universally  adopted,  and  are  indispensable  for  the 
practical,  qualitative  testing  of  free  HCl. 

iGriinzburg's  Reagent. — The  principle  of  the  reaction,  which  has 
long  been  known  to  chemists,  is  that  a  pine  needle  which  has  been 
dipped  into  a  solution  of  phloroglucin  will  assume  a  bright  red  color 
when  it  is  brought  in  contact  with  hydrochloric  acid.  Max  Singer 
has  shown  that  this  color  change  is  due  to  the  presence  of  vanillin. 
The  solution  is  made  as  follows  : 

Phloroglucin 2'0  [gr.  xxx] 

Yanillin 1"0  [gr.  xv] 

Absolute  alcohol 30-0  [f  §  j] 

The  solution  is  pale  yellow  in  color,  and  has  a  pronounced  odor  of 
vanilla  or  fresh  pine  wood ;  on  exposure  to  light  it  in  time  assumes 
a  dark  golden-yellow  color,  and  it  must  therefore  be  kept  in  black 
bottles.  If  a  drop  of  the  reagent  is  put  into  a  small  porcelain  dish 
and  some  concentrated  hydrochloric  acid  is  added,  a  bright  red  color 
and  the  formation  of  small  red  crystals  will  be  at  once  observed. 
If  the  acid  is  weaker,  as,  for  example,  only  0'05  per  cent  or  less,  or 
with  stomach  contents,  no  change  will  be  observed  at  first ;  but  if 
the  dish  is  carefully  heated  over  a  flame,  so  that  the  fluid  does  not 
boil,  but  simply  evaporates  slowly,  at  the  edge  of  the  drop  a  bright 
red  tinge  or  very  dehcate  red  stripes  will  be  observed.  These  are 
absolute  proofs  of  the  presence  of  free  hydrochloric  acid.  Blowing 
on  the  dish  will  cause  the  beautiful  red  stripes  to  appear  at  once. 
Filtration  of  the  gastric  contents  is  unnecessary ;  one  or  two  drops 
in  a  small  dish  or  on  a  strip  of  filter  paper  with  an  equal  quan- 
tity of  the  reagent  will  sufiice.  Test  papers  may  be  prepared  by 
soaking  strips  of  ash-free  filter  paper  in  the  reagent  and  drying 
them.     A  drop  of  stomach  contents  is  placed  upon  the  strip ;  on 

cyanide  of  potassium  and  acetate  of  iron  ;  a  peach-red  precipitate  of  sulpho-cyanide 
of  iron  is  thrown  down.  Reoch  used  tartrate  of  sodium  ferric  oxide  for  the  same 
purpose.     Kahler  proposed  ultramarine  and  zinc  sulphide. 

*  Giinzbnrg.  Neue  Methode  zum  Nachweis  freier  Salzsaure  im  Mageninhalt. 
Centralblatt  f  ilr  klinische  Medicin,  1887,  No.  40. 

f  Boas.  Ein  neues  Reagens  f iir  den  Nachweis  freier  Salzsaure  im  Magensaft. 
Centralblatt  fur  klin.  Med.,  1888,  JSTo.  45.  [Priedenwald,  N.  Y.  Medical  Record, 
October  6,  1894.— Ed.] 


THE   TESTS  FOR  HYDROCHLORIC   ACID.  39 

heating  this  in  a  porcelain  capsule  a  distinct  reaction  may  be  ob- 
tained (Boas).  But  not  even  tliis  is  necessary.  It  will  suffice  to 
take  the  minute  quantity  of  stomach  contents  which  is  held  in  the 
eye  of  a  piece  of  wire  which  has  been  bent  over  into  a  loop  the  size 
of  a  pin's  head.  Rub  this  upon  a  porcelain  capsule  or  upon  the 
tip  of  a  porcelain  spoon,  and  add  an  equal  quantity  of  reagent ;  on 
heating,  a  distinct  reaction  will  be  obtained.  The  reaction  has  this 
great  advantage  over  all  others,  that  it  is  only  produced  hy  IlCl 
and  not  by  organic  acids,  and  that  it  is  not  simulated  by  the  albu- 
minates which  may  be  present;  neither  is  it  interfered  with  by 
salts,  '  provided  they  are  within  the  usual  proportion ;  nor  is  it 
affected  by  organic  acids ;  but  of  this  I  shall  speak  again  later  on. 
It  is  sufficiently  delicate,  since  a  distinct  reaction  may  be  obtained 
with  even  0*05  per  mille  [1 :  20000]  HCl. 

The  color  obtained  is  always  a  bright  red,  but  where  the 
amounts  are  very  small  it  may  be  a  pale  rose  red,  yet  it  is  never 
brown  nor  brownish  yellow  nor  brownish  red.  The  presence  of 
such  shades  indicates  overheating  and  the  combustion  of  organic 
substances.  Characteristic  is  the  appearance  of  red  stripes  or  of  a 
uniform  reddish  tinge  at  the  edge  of  the  drop  after  gentle  heating 
or  slow  evaporation  to  dryness.  Strong  heating  and  evaporation  of 
any  albuminous  substance  will  produce  a  marked  centred  red  colora- 
tion, yet  this  is  scarcely  to  be  confounded  with  hydrochloric-acid 
reaction.  If  dilute  hydrochloric  acid  is  added  to  solutions  of  albu- 
men or  peptone,  then  the  above-mentioned  reaction  of  these  sub- 
stances will  only  occur  after  their  affinity  for  the  acid  has  been  com- 
pletely satisfied. 

Boas' s  Reagent  consists  of 

Besorcin  resubhmat 5*0  [gr.  Ixxv] 

Sacchar.  alb 3"0  [gr.  xlv] 

Spiritus  dilut 100-0  [f  3  iijss.] 

The  reaction  is  carried  out  in  the  same  way  as  with  Glinzburg's  re- 
agent ;  the  color  ]3roduced  is  the  same,  but  it  is  slower  in  making 
its  appearance,  and,  in  heating,  greater  care  must  be  taken  lest  the 
charring  of  the  sugar  lessens  the  cleanliness  of  the  reaction.  The 
rose-red  colored  spot  which  appears  on  heating  the  test  paper  is  not 

decolorized  by  ether. 
4 


40  DISEASES  OP  THE  STOMACH. 

[The  only  advantages  whicli  Boas's  test  has  over  that  of  Grlinz- 
burg  are  that  it  is  much  cheaper  and  more  stable.  It  may  be  kept 
unchanged  for  a  very  long  time.] 

\Td])fer's  Test. — Topfer  *  has  recently  proposed  a  test  for  free 
HCl  which  is  exceedingly  delicate,  and  which  has  the  additional  ad- 
vantage that  it  may  also  be  used  in  quantitative  analyses  for  the  vari- 
ous combinations  of  HCl  (see  page  47).  His  reagent  is  a  one-haK- 
per-cent  alcoholic  solution  of  dimethylamidoazobenzol,  which  turns 
red  even  in  the  presence  of  ^l  per  mille  (1  to  40,000)  HCl.  It 
may  be  used  either  in  solution  or  as  a  test  paper,  the  latter  being 
less  delicate  than  the  former.  It  is  used  as  follows :  To  a  few  cubic 
centimetres  of  filtered  stomach  contents  in  a  test  tube  or  beaker 
add  one  drop  of  the  test  solution ;  if  free  HCl  is  present  it  will  turn 
red.  The  test  papers  are  prepared  by  dipping  strips  of  filter  paper 
into  the  test  solution  ;  on  drying  they  turn  yellow.  On  dipping  the 
test  paper  into  stomach  contents  with  free  HCl  a  red  color  appears. 

Topfer  and  Friedenwald  claim  that  this  reagent  responds  only 
to  free  HCl,  and  not  to  combined  HCl  or  organic  acids.  It  has  been 
shown,  however,  by  Strauss  f  and  Einhorn,;}:  that  it  also  responds  to 
moderately  concentrated  solutions  of  acid  phosphates  and  solutions 
of  lactic  acid  in  the  concentrations  in  which  it  occurs  in  the  stom- 
ach. Einhorn  believes  that  if  lactic  acid  is  shown  to  be  absent  by 
Uffelmann's  test  we  have  an  excellent  means  of  determining  the 
amount  of  free  HCl. 

For  the  use  of  this  test  for  quantitative  work,  see  page  48.] 

The  Tests  for  Organic  Acids, — i.  e.,  lactic,  acetic,  and  the  true  fatty 
acids,  especially  butyric  acid — ^must  now  be  considered.  I  have 
already  discussed  the  occurrence  of  lactic  acid  in  the  earliest  stages 
of  digestion.  But  it  is  pathological  if  it  or  other  organic  acids  are 
found  in  such  quantities  that  they  may  readily  be  detected  by  the 
ordinary  tests.  It  is  characteristic  of  these  acids  that  they  are  deriv- 
atives of  the  substances  which  occur  normally  in  the  chyme — 
i.  e.,  starches,  sugars,  fats,  and  proteids — and  that  they  are  produced 


*  [Topfer.   Zeitschr.  fiir  physiolog.  Chemie,  Bd.  xix,  Heft  1.     Friedenwald.  N.  Y. 
Medical  Record,  April  6,  1895.— Ed.] 

f  [Strauss.     Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  Iv.— Ed.J 

X  [Einhorn.     N.  Y.  Medical  Journal,  May  9,  1896,  p.  603.— Ed.] 


THE  TESTS  FOR  LACTIC   ACID.  41 

from  them  by  fermentation.  So  far  as  we  know,  tlie  only  one 
which  is  not  so  formed  is  sarcolactic  acid,  which  is  dissolved  from 
meat  in  which  it  is  always  present. 

Tests  for  Lactic  Acid. — There  are  two  kinds  of  lactic  acid  :  fer- 
tnentation  lactic  acid  and  sarcolactic  acid.  They  are  distinguished 
not  so  much  by  differences  in  chemical  character  as  by  their  source. 
The  former  is  of  more  importance  to  us  than  the  latter,  yet  the 
tests  to  be  described  presently  apply  to  both  kinds.  The  method 
used  by  chemists  to  determine  the  presence  of  lactic  acid  is  a  very 
elaborate  one,  and  is  too  complicated  for  general  use.  A  very  sim- 
ple and  rapid  test  for  medical  practice  has  been  proposed  by  Uffel- 
mann.  Diluted  solutions  of  neutral  ferric  chloride  turn  canary 
yellow  or  greenish  yellow  in  the  presence  of  lactic  acid.*  If  some 
ferric  chloride  solution  is  diluted  till  it  is  almost  colorless,  and  a  trace 
of  lactic  acid  is  added,  a  canary -yellow  color  will  at  once  appear. 
Nevertheless,  the  reaction  is  somewhat  uncertain,  or  rather  difficult 
of  recognition,  because  we  must  merely  distinguish  the  intensity  of 
otherwise  similar  shades  of  color.  Hence  the  test  was  modified  by 
adding  one  or  two  drops  of  pure  carbolic  acid  to  the  above  solution ; 
or  a  few  c.  c.  of  a  dilute  carbolic  acid  solution,  say  10  c.  c.  [3  ijss.] 
of  a  2  to  5  per  cent  solution  of  carboKc  acid — ^the  exact  proportions 
are  not  essential — are  mixed  with  one  or  two  drops  of  ferric  chloride 
solution  and  diluted  with  water  till  the  solution  assumes  a  beautiful 
amethyst-blue  color.  The  addition  of  lactic  acid  changes  the  color  to 
the  same  canary  or  greenish  yellow  described  above,  and  a  good  con- 
trast is  thus  obtained.  A  few  drops  of  even  a  0*05  per  thousand  solu- 
tion of  lactic  acid  [1  in  20,000]  will  suffice  to  change  this  blue  to 
the  characteristic  yellow  color.  The  delicacy  of  the  reaction  is  such 
that  2  c.  c.  [3  ss.]  of  this  Uffelmann's  reagent  will  give  a  distinct  re- 
sult on  adding  0*8  c.  c.  [12  minims]  of  a  lactic  acid  solution  of  0*01 
per  cent ;  with  0*6  c.  c.  [9  minims]  of  the  same  solution  the  color  is 
pale  yellow ;  but  no  yellow  color  is  recognizable  on  adding  only  0*3 
c.  c.  [4r^  minims].    The  reagent  soon  decolorizes,  and  hence  must  be 


*  [All  recent  writers  lay  great  stress  upon  the  greenish  color  of  the  reaction ; 
when  in  doubt  as  to  the  exact  color  it  is  wise  to  add  a  drop  of  lactic  acid  to  a  small 
quantity  of  UflFelmann's  reagent  in  a  test  tube  and  to  use  this  as  a  standard  for 
comparison. — Ed.] 


42  DISEASES  OP  THE  STOMACH. 

freshly  prepared  each  time  before  using  it,  I  have  found,  how- 
ever, that  it  may  be  kept  unchanged  for  some  time  by  adding  about 
5  per  cent  chloroform  and  preserving  it  in  dark  bottles. 

Unfortunately,  this  test  is  not  entirely  free  from  sources  of  error, 
since  lactates  as  well  as  free  lactic  acid  produce  the  yellow  color. 
This,  however,  does  not  make  much  difference,  for  it  is  immaterial 
to  us  whether  free  lactic  acid  or  lactates  are  present ;  we  simply 
wish  to  ascertain  the  presence  of  lactic  acid  in  the  stomacli.  But 
the  reaction  can  also  be  caused  by  alcohol,  sugar,  and  certain  salts, 
especially  phosphates,  which  are  frequently  found  in  the  contents 
of  the  stomach.  Thus,  a  drop  of  Rhine  wine  will  give  a  decided 
yellow  color,  and  even  the  ethereal  extract  of  a  tablespoonful  of 
Rhine  wine  or  claret  will  do  the  same.  We  must  therefore  be  care- 
ful to  ascertain  whether  the  patient  has  taken  any  wine  or  alcohol 
before  making  the  test.  If  to  Uffelmann's  reagent  we  add  some 
phosphate,  as,  for  example,  a  little  phosphate  of  soda  in  solution, 
its  color  will  change  to  canary -yellow  which  is,  however,  different 
from  the  characteristic  tinge  ;  but  if  the  stomach  contents  have  a 
yellowish  hue  of  their  own,  then  the  resemblance  may  be  very 
close. 

Under  such  circumstances  we  are  compelled  to  resort  to  a  modi- 
fication of  the  method  used  by  chemists — i.  e.,  we  must  make  an 
ethereal  extract  of  the  fluid  to  be  examined,  then  evaporate  it,  and 
apply  the  reaction  on  the  residue  left  after  evaporation.  This 
method  is  very  simple.  Take  some  gastric  juice  with  an  acid  reac- 
tion, which  gives  a  marked  yellow  color  with  Uffelmann's  reagent, 
and  which  shows  no  reaction  for  free  acid  with  Giinzburg's  test 
or  tropseolin,  but  which  does  give  a  reaction  with  Congo  red ;  we 
must  ascertain  whether  the  yellow  color  is  due  to  traces  of  free 
lactic  acid  or  lactates  or  acid  salts.  Lactic  acid  may  easily  be  ex- 
tracted with  ether  from  solutions  of  O'YS  to  0'5  per  thousand; 
hence,  if  free  lactic  acid  be  present,  the  aqueous  solution  of  the 
residue  left  after  evaporating  the  ethereal  extract  ought  to  react 
acid.  First,  we  extract  with  ether.  We  may  do  this  by  using  a  so- 
called  "separatory  funnel"  {SGheidetrichter\  or  more  simply  by 
thoroughly  shaking  about  5  to  10  c.  c.  [  3  ji  to  3  ijss.]  of  the  stom- 
ach contents  in  a  medicine  bottle  with  alcohol-free  ether ;  let  the 


TESTS  FOR  LACTIC   ACID.  43 

ether  separate,  which  usually  occurs  very  rapidly,  and  pour  it  off 
into  a  small  glass  beaker.  This  is  repeated  with  fresh  portions  of 
ether  till  we  have  used,  all  told,  about  30  to  60  c.  c.  [f  3  j-ij]  of  ether. 
The  ether  is  then  evaporated  without  an  open  flame  by  placing  the 
glass  beaker  in  a  vessel  of  hot  water.  Add  a  few  drops  of  water  to 
the  residue,  and  with  this  try  Uffelmann's  reaction  by  carefully  let- 
ting one  or  two  drops  of  the  reagent  flow  from  a  pipette.  The  re- 
agent and  the  substance  to  be  tested  must  always  bear  a  definite  re- 
lation to  each  other.  If  we  add  too  much,  the  reaction  might  be  con- 
cealed. The  residue  after  evaporation  was  acid,  and  gave  a  distinct 
Uflelmaim  reaction.  Since  in  this  experiment  no  reaction  for  free  acid 
was  obtained  with  tropseolin,  it  will  show  how  much  more  delicate 
Ufl^elmann's  reagent  is  than  tropseolin.  The  latter  gave  no  reaction 
for  free  acid  because  it  was  masked  by  acid  salts,  and  because  only 
minute  traces  of  lactic  acid  were  present ;  yet  the  Congo-red  tesc 
for  free  acid  was  positive,  and  the  TJifelmann  test  showed  that  this 
was  lactic  acid. 

[In  spite  of  all  the  work  which  has  recently  been  done  on  the 
tests  for  lactic  acid,  it  is  generally  conceded  that,  after  all,  Uffel- 
mann's  test  is  sufficiently  reliable  for  practical  purposes,  since  the 
quantities  of  lactic  acid  which  have  any  pathological  significance 
must  be  so  large  that  they  can  readily  be  detected  with  this  reagent. 
Several  useful  modifications  have  been  proposed.  Thus  Fleischer  * 
does  not  evaporate  the  ether,  but  adds  the  freshly  prepared  Uffel- 
mann  reagent  to  the  mixture  of  ether  and  stomach  contents,  and 
shakes  vigorously ;  if  lactic  acid  is  present  a  yellow  zone  appears  at 
the  bottom  of  the  test  tube. 

Strauss  f  has  devised  a  special  separatory  funnel  which  is  gradu- 
ated at  5  c.  c.  and  25  c.  c.  Five  cubic  centimetres  stomach  contents 
are  poured  in,  and  then  add  20  c.  c.  ether ;  shake  well,  then  allow 
20  c.  c,  to  run  oif  by  opening  the  stopcock  at  the  lower  end  of  the 
funnel ;  dilute  the  remaining  5  c.  c.  by  adding  20  c.  c.  distilled  water ; 
then  add  2  drops  of  a  10  per  cent  aqueous  solution  of  ferric  chloride ; 
shake  well,  and  an  intense  greenish-yellow  color  will  be  observed. 

*  [Fleischer.  Quoted  by  Penzoldt,  Deutsch.  Arch,  fiir  klin.  Med.     Bd.  ii,  p.  544, 
—Ed.] 

t  [Strauss.    Berl.  klin.  Wochenschr.,  1895,  No.  37.— Ed.] 


44  DISEASES  OF   THE   STOMACH. 

Boas's  qualitative  test*  for  lactic  acid  is  too  complicated 
for  clinical  purposes ;  its  principle  is  tlie  oxidation  of  the  lac- 
tic acid  into  aldehyde,  which  is  then  detected  by  Nessler's  re- 
agent.f 

The  diagnostic  significance  of  lactic  acid  will  be  discussed  in  the 
chapter  on  Cancer  of  the  Stomach.] 

The  fatty  acids,  and  especially  butyric  acid,  decolorize  Uffel- 
mann's  reagent ;  but  this  occurs  only  when  they  are  present  in  over 
0-5  per  thousand  [1  in  2,000].  Fat  in  the  stomach  contents  may 
be  easily  recognized  by  the  small  oily  particles  which  are  to  be 
found  in  the  aqueous  solution  of  the  residue  left  after  evaporating 
the  ethereal  extract.  The  butyric  acid  which  is  present  in  this 
same  aqueous  solution  may  be  separated  in  the  form  of  oily  drops 
by  adding  some  small  pieces  of  calcium  chloride.  Large  quantities 
of  fatty  acids  in  the  chyme  may  be  recognized  by  the  characteristic 
acrid,  rancid  odor. 

The  best  practical  test  for  acetic  acid  is  the  nose.  If  present  in 
considerable  quantity  its  odor  is  unmistakable.  It  may  be  de- 
tected by  neutralizing  the  watery  residue  of  the  ethereal  extract 
with  carbonate  of  soda  and  then  adding  neutral  ferric  chloride  solu- 
tion. A  beautiful  blood-red  color  is  struck,  which  can  only  be  ob- 
tained by  one  other  substance — formic  acid — ^but  this  does  not  occur 
in  the  contents  of  the  stomach. 

Finally,  one  other  substance — alcohol — is  to  be  mentioned ;  it  is 
to  be  found  only  in  the  rare  cases  of  marked  yeast  fermentation  in 
the  stomach.  It  may  be  detected  with  the  Lieben  iodoform  reac- 
tion in  the  distillate  of  the  stomach  contents ;  but  we  must  be  cer- 
tain that  the  patient  has  not  taken  alcohol  for  some  time,  either  in 
beverages  or  medicines  (tinctures,  fluid  extracts,  etc.).  The  demon- 
stration of  alcohol  has  no  practical  value,  hence  I  shall  omit  giving 
exact  details  of  the  method. 

[A  number  of  other  substances  which  are  the  result  of  abnormal 
fermentations  and  putrefaction  of  the  carbohydrates  and  albumi- 
noids when  there  is  marked  stagnation  of  the  stomach  contents  are 

*  [See  Boas,  loc.  cit.,  or  Friedenwald,  loc.  cit. — Ec] 

f  [An  excellent  critical  resume  of  the  various  tests  for  lactic  acid  has  recently 
been  published  by  De  Jong.    Boas'  Archiv,  Bd.  ii,  Heft  1,  p.  53. — Ed.] 


FERMENTATION  PRODUCTS.  45 

acetone,  methane,  snlpliureted  liydrogen,  and  ammonia.  The  cause 
is  nsually  bacteriah 

The  fermentation  of  carbohydrates  produces  lactic,  but}Tic,  and 
acetic  acids,  and  possibly  also  hydrogen ;  furthermore,  as  the  result 
of  yeast  fermentation,  alcohol  and  carbonic  acid  are  produced.  The 
putrefaction  of  albuminoids  results  in  ammonia,  sulphureted  hy- 
drogen, and  methane. 

Rosenheim  and  Strauss  *  have  shown  that  traces  of  ammonia 
may  occur  normally  in  the  stomach  ;  carbonic-acid  gas  may  also  be 
regarded  as  a  normal  product  in  the  stomach. 

The  relations  of  sulphureted  hydrogen  have  been  studied  by 
Boas  and  Zawadski.f  Boas  claims  that  this  gas  occurs  especially 
in  dilatation  of  the  stomach  due  to  benign  stenoses,  and  that  it  is 
not  found  when  the  cause  of  the  pyloric  stenosis  is  malignant.  It 
occurs  even  when  HCl  is  present  in  normal  amounts.  Zawadski 
only  found  it  when  the  stomach  contents  had  stagnated  over  24 
hours.  It  may  readily  be  detected  by  its  characteristic  odor  of 
rotten  eggs,  and  also  by  the  blackening  of  a  strip  of  filter  paper 
moistened  with  alkaline  sugar-of-lead  solution,  which  is  hung  in  a 
well-corked  test  tube  containing  some  of  the  stomach  contents. 

The  occurrence  of  this  gas  and  of  methane  will  be  discussed  in 
Chapter  YI,  where  the  subject  of  fermentation  and  putrefaction 
will  be  considered  in  detail.  It  is  to  be  noted  that  Betz  and  Sena- 
tor have  found  HgS  in  acute  gastric  catarrh,  and  Emminghaus  has 
observed  it  in  a  case  where  there  was  a  communication  between  the 
stomach  and  the  perforated  intestines. 

Acetone  has  also  been  found  in  stagnating  stomach  contents  by 
Yon  Jaksch  and  Lorenz  ;  :j:  these  writers  also  claimed  to  have  found 
it  in  other  conditions.  Penzoldt  and  SavehefE  *  maintain  that  they 
have  never  been  able  to  find  it. 

Ptomaines  have  also  been  extracted  from  stagnating  stomach  con- 

*  [Rosenheim.  Centralblatt  fiir  klin.  Med.,  1893,  No.  32.  Strauss.  Berl.  klin. 
Wochenschr.,  1893,  No.  17.— Ed.] 

f  [Boas.  Loc.  cit.,  part  i,  p.  209.  Zawadski.  Centralblatt  fiir  innere  Medicin, 
1894,  No.  50.— Ed.] 

:|:  [Von  Jaksch.  Zeitschr.  fiir  klin.  Med.,  Bd.  viii,  p.  36.  Lorenz.  Ibid.,  Bd. 
viii,  p.  36.— Ed.] 

*  [SaveliefE.    Berl.  klin.  Wochensehr.^  August  13,  1894.— Ed.] 


46  DISEASES  OP   THE  STOMACH. 

tents  in  gastrectases  due  to  benign  and  cancerous  pyloric  stenosis.* 
Ptomaines  seem  to  play  an  important  part  in  the  causation  of 
tetany  (see  Chapter  YI). 

Strauss  f  has  recently  reported  a  case  in  which  both  sulphureted 
hydrogen  and  indol  were  found ;  he  was  able  to  cultivate  the  bacil- 
lus coh  communis  from  the  stomach  contents.  In  cultures  this 
bacillus  produced  HaS.] 

The  duantitative  Determination  of  Acidity. — The  quantitative  de- 
termination of  the  amount  of  HCl  secreted  must  determine  two 
things :  (1)  The  amount  of  free  HCl ;  (2)  the  amount  of  HCl 
which,  as  explained  above  (page  25),  has  combined*  with  bases  and 
organic  substances.  The  sum  of  (1)  and  (2)  will  give  the  total 
amount  of  HCl  secreted.  This  value,  however,  can  only  be  de- 
termined if  we  introduce  food  into  the  stomach  which  is  totally 
free  from  chlorides,  or  if  the  amount  of  chlorides  which  has  been 
introduced  is  exactly  known.  Both  of  these  procedures  would  be 
very  difficult,  and  would  scarcely  be  feasible  for  ordinary  practical 
work ;  and,  furthermore,  for  the  following  reasons  they  are  un- 
necessary. It  is  true  that  with  the  test  dinner,  and  especially  with 
the  test  breakfast,  we  introduce  a  certain  quantity  of  chlorides  and 
bases,  the  latter  of  which  are  converted  into  chlorides  by  the  HCl 
which  is  secreted ;  yet  we  have  at  present  no  simple  method  with 
which  we  can  distinguish  the  chlorine  of  the  chlorides  which  are 
introduced  into  the  stomach  and  those  which  are  formed  there. 
On  the  contrary,  in  the  ordinary  methods  of  analysis  the  chlorine  of 
the  total  chlorides  is  ascertained  and  is  calculated  as  HCl.  But  the 
chlorides  which  have  been  introduced  do  not  interest  us.  The 
chlorine  which  they  contain  has  nothing  to  do  with  the  work  of  the 
stomach,  and  is  a  variable  factor  which  differs  in  the  various  cases, 
which,  for  example,  varies  if  the  bread  or  the  dinner  which  is  eaten 
contains  more  salt  than  usual.  At  all  events,  the  bases  and  weaker 
salts  are  converted  into  chlorides  by  the  secreted  HCl,  and  thus 
take  up  a  certain  quantity  of  the  secreted  HCl ;  yet  this  is  only  a 
very  small  fraction  of  the  total   amount   of  HCl.     !N^ow,   as  the 

*  [Kulneff.     Berl.  klin.  Wochenschr.,  1893,  No.  17.     Turck.     Toxines  of  the 
Stomach,  N.  Y.  Medical  Journal,  February  32,  1896.— Ed.] 
■<•  [Strauss,  Berl.  klin.  Wochenschr.,  May  4,  1896.— Ed.] 


QUANTITATIVE  TESTS  FOR  FREE   HYDROCHLORIC   ACID.     47 

amount  of  bases  which  are  introduced  with  every  test  breakfast  is 
about  the  same,  and  at  all  events  differs  to  a  much  less  degree  than 
the  chlorides,  and  especially  sodium  chloride,  we  may  once  for  all, 
without  committing  any  great  error,  eliminate  this  factor  and  restrict 
ourselves  to  the  estimation  of  the  amount  of  HCl  combined  with 
organic  substances.  This  is  the  more  justifiable  because  the  HCl 
which  has  combined  to  form  chlorides  has  been  lost  for  actual  diges- 
tive purposes.  Our  task  is  therefore  simplified  by  having  to  estimate 
only  the  amount  of  the  free  HOI,  and  of  ths  SOI  which  has  com- 
hined  with  organic  bodies — i.  e.,  the  physiologically  active  HOI. 

I  believe  the  views  which  have  just  been  enunciated  will  dispose 
of  the  demand  made  by  Martius  and  Liittke,*  that  the  unfiltered 
and  not  the  filtered  stomach  contents  be  employed ;  for,  as  already 
explained  on  pages  31  and  32,  we  are  always  only  dealing  with  rel- 
ative values,  in  which,  for  practical  diagnostic  purposes,  it  makes 
very  little  difference  whether  they  are  absolutely  or  approximately 
estimated.  Also  in  the  method  of  these  two  writers,  as  will  be 
shown  later  on,  the  chlorine  which  has  combined  with  the  bases  is 
neglected,  and  therefore  no  attempt  is  made  to  calculate  the  abso- 
lute quantity  of  HCl  secreted,  even  if  we  disregard  the  fact  that 
this  method  also  gives  by  no  means  accurate  results. 

In  order  to  simplify  matters  I  shall  follow  the  suggestion  of 
Mintz,  and  designate  and  tabulate  the  various  factors  under  discus- 
sion as  follows,  because,  as  shown  by  the  hterature  of  the  past  few 
years,  there  has  been  much  confusion  on  this  subject,  not  alone 
among  general  practitioners,  but  also  among  writers. 

A  =  Aciditas  =  Total  acidity. 

L  =  Acid,  hydrochlor.  liberum  =  Free  HCl  (or  the  chlorine  con- 
tained in  it). 

C  =  Acid,  hydrochlor.  combinatum  =  Loosely  combined  HCl  (or 
the  chlorine  combined  with  organic  bodies). 

F  =  Chlorum  fixum  =  Chlorides  (or  chlorine  of  the  mineral 
salts). 

T  =  Chlorum  totale  =  Total  chlorine. 

The  Estimation  of  Free  HCl  (L). — This  is  best  made  with  Mintz' s 

*  hoc.  cit.,  p.  30. 


4S  DISEASES  OF  THE  STOMACH. 

method  /  *  deci-normal  soda  solution  is  added  [from  a  burette]  to  10 
c.  e.  of  stomach  contents  till  Giinzburg's  or  Boas's  reaction  no  longer 
occurs  /  here  the  quantity  of  alkali  corresponds  to  the  amount  of 
free  hydrochloric  acid  which  is  present.  Mintz  has  estimated  the 
limits  of  the  Giinzburg  reaction  to  be  0-036  per  mille  HCl  (i.  e., 
1  c.  c.  deci-normal  soda  solution  to  100)  ;  he  has  also  demonstrated  by 
special  experiments  that  even  in  mixtures  of  albuminous  substances 
and  hydrochloric  acid  the  alkali  combines  first  with  the  free  HCl. 
For  example,  if  the  Giinzburg  reaction  no  longer  occurs  after  add- 
ing 1-3  c.  c.  deci-normal  soda  solution  to  10  c.  c.  stomach  contents, 
and  is  still  positive  when  only  1*2  c.  c.  of  the  soda  solution  have 
been  added,  then  the  amount  of  free  HCl,  as  calculated  for  100  c.  c. 
stomach  contents,  equals  13  c.  c.  deci-normal  soda  solution  (i.  e., 
12  +  1)  ;  this  represents  0-04:7  per  cent  HCl.f  If  Giinzburg's  test 
is  used,  as  described  on  page  39,  the  amount  of  stomach  contents 
used  in  testing  is  exceedingly  small,  even  if  repeated  tests  be  made, 
for  each  time  we  need  only  as  much  as  is  taken  up  by  a  small  loop 
of  wire.  \ 

As  soon  as  the  point  is  reached  where  Giinzburg's  test  is  nega- 
tive, a  few  drops  of  phenol  phthalein  solution  may  be  added  to  the 
filtrate  of  the  stomach  contents,  and,  as  already  described,  the  total 
acidity  may  be  determined.  Thus  we  may  at  once  determine  both 
the  amount  of  free  HCl  (L)  and  the  total  acidity  (A). 

[The  amount  of  free  HCl  and  the  total  acidity  may  also  be  de- 
termined with  Topfer's  reagent  (see  page  40).  At  the  same  time 
we  can  also  ascertain  the  amount  of  loosely  combined  HCl  and  that 
due  to  the  organic  acid  -f-  acid  salts.  This  is  accomplished  by 
means  of  various  indicators. 


*  S.  Mintz.  Eine  einfache  Methode  zur  quantitativen  Bestimmung  der  freien 
Salzsaure  im  Mageninhalt.  Wiener  klin.  Wochenschrift,  1889,  No.  20,  and  1891, 
No.  9. 

t  [13  X  0-003646  (1  c.  c.  ^  normal  soda  solution  =  0-003646  HCl)  =  0-047398  per 
cent  HCL— Ed.] 

X  Boas  (Diagnostik  und  Therapie  der  Magenkrankheiten,  2te  Aufl.,  Bd.  i, 
p.  168)  has  proposed  the  opposite  method,  namely,  of  titrating  with  deci-normal 
HCl,  to  determine  the  value  of  the  combined  HCl.  But,  disregarding  the  fact  that 
Mintz  has  proposed  his  method  only  "  for  the  HCl,  which  is  not  demonstrable  with 
Giinzburg's  reagent,"  A.  Meyer  (Inaug.  Dissert..  Berlin,  1890)  has  already  shown 
that  the  combined  HCl  can  not  be. determined  in  this  way. 


QUANTITATIVE  TESTS  FOR  COMBINED  HYDROCHLORIC  ACID.   49 

The  method  is  as  follows :  The  reagents  required  are  deci-normal  soda 
solution,  phenol-j)hthalein  solution,  Topfer's  reagent,  and  1  per  cent 
aqueous  solution  of  sodium  alizarin  sulphonate. 

Place  10  c.  c.  of  the  stomach  contents  in  three  beakers,  A,  B,  and  C 
To  beaker  A  add  two  drops  of  the  phenol -phthalein  solution  and  deter- 
mine the  total  acidity  by  adding  deci-normal  soda  solution  until  a  per- 
manent red  color  is  obtained.  To  beaker  B  add  three  or  four  drops  of  the 
alizarin  sulphonate  solution  and  add  deci-normal  soda  solution  until  the 
first  appearance  of  a  distinct  violet  tint.  All  the  factors  of  the  acidity 
excepting  the  loosely  combined  HCl  act  on  alizarin.  Hence  the  difference 
between  B  and  A  =  loosely  combined  HCl.  To  beaker  C  add  three  or 
four  drops  of  Topfer's  reagent  and  add  deci-normal  soda  solution  until  the 
last  trace  of  red  has  disappeared,  leaving  only  a  yellow  tint.  This  gives 
the  amount  of  free  HCl.  By  subtracting  the  results  of  the  free  and 
loosely  combined  HCl  from  the  total  acidity  we  will  obtain  the  acidity 
due  to  the  organic  acids  and  acid  salts.*] 

Estimation  of  the  Loosely  Combined  HCl  (C). — A  great  many  tests 
liave  been  proposed  for  this  purpose,  of  whicli  Martins  and  Liittke 
have  enumerated  and  carefully  described  no  less  than  twelve.f  The 
principle  of  all  these  methods  is  to  ascertain  the  total  quantity  of 

*  [Leo's  Diagnostik  der  Krankheiten  der  Bauchorgane,  2te  Auflage,  p.  319. — Ed.] 
f  In  addition  to  those  which  will  be  described  in  the  text  these  may  be  briefly 
recapitulated  as  follows : 

1.  Bidder  and  Schmidt's  method  for  the  determination  of  the  total  HCl.  See 
Ewald,  Klinik,  etc.,  Bd.  i,  3te  Auflage,  p.  81. 

2.  Rehner  and  Seemann's  Method. — Incineration  after  adding  enough  alkali  to 
neutralize  {a) ;  estimation  of  acidity  of  the  ash  (6).  Then  a  —  b  =  free  +  combined 
HCl.     Zeitschr.  fiir  klin.  Med ,  Bd.  v,  p.  272. 

3.  Braun's  modification  of  this  method,  described  by  Leube.  Spec.  Diagnostik, 
etc.,  2d  edition. 

4.  Cahn  and  Von  Mering's  Method. — After  the  HCl  has  been  combined  with  cin- 
chonin,  it  is  separated  and  the  amount  of  chlorine  contained  therein  is  estimated. 
Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  xxxix,  p.  293. 

5.  HoffmanJi's  Method. — This  is  based  on  the  inverting  action  on  sugar  of  HCl 
solutions.     Centralbl.  fiir  klin.  Med.,  1889,  No.  46. 

6.  Jones's  Method. — The  spectra  of  watery  solutions  of  eosin  have  two  absorp- 
tion bands  which  disappear  when  free  and  combined  HCl  are  present.  One  fifth 
normal  alkali  is  added  to  the  stomach  contents  until  the  absorption  bands  appear ; 
the  HCl  is  calculated  from  the  amount  of  alkali  used.  Wiener  med.  Presse,  1890, 
No.  51. 

7.  Sjoqvisfs  Method. — By  incineration  with  barium  carbonate  the  free  and  com- 
bined HCl  are  converted  into  barium  chloride,  which  may  then  be  calculated  ac- 
cording to  different  methods.  Zeitschr.  fiir  physiolog.  Chem.,  Bd.  xiii,  p.  1.  See 
also  Katz.  Wiener  med.  Woehenschr.,  1890,  No.  51.  Von  Jaksch.  Klinische  Diag- 
nostik, 3te  Auflage,  1892.  Fawitzki.  Virchow's  Arch.,  Bd.  cxxiii,  p.  307;  and 
Bourget.     Arch,  de  med.  Experim.,  1889,  No.  6,  p.  844. 

8.  Winter  and  Hayem's  Method. — Incineration  (after  the  addition  of  soda)  and 
estimation  of  the  chlorine  with  deci-normal  silver  nitrate  with  three  portions  of 


50  DISEASES  OP   THE  STOMACH. 

the  free  and  loosely  combined  HCl  (L  -\-  C),  and  then  by  ascertain- 
ing and  subtracting  the  amount  of  free  HCl  to  obtain  the  quantity 
of  the  loosely  combined  HCL  The  sum  L  -f-  C  is  estimated  either 
by  direct  analysis  or  by  first  obtaining  the  total  amount  of  chlorine 
(T)  and  then  subtracting  the  chlorine  in  the  chlorides  (F).  I  have 
studied  and  employed  all  these  various  methods,  but  consider  it 
superfluous  to  enter  into  a  detailed  criticism  of  them;  instead,  I 
shall  confine  myself  to  a  description  of  two  of  them,  which,  on  ac- 
count of  their  simplicity,  may  be  recommended  for  practical  use. 
Although  they  are  not  free  from  sources  of  error,  yet  their  results 
are  sufliciently  accurate  for  practical  purposes.  If  we  will  only 
consider  upon  how  many  uncontrollable  factors  the  amount  of  HCl 
secreted  at  the  time  of  our  examination  depends,  we  will,  I  believe, 
refrain  from  demanding  of  our  analytical  procedures  a  delicacy 
which  can  only  be  deceptive  and  which  leads  to  false  conclusions 
when  the  methods  are  put  to  practical  use. 

Leo's  Method. — This  method  is  based  upon  the  fact  that  calcium 
carbonate  (CaCOg)  at  ordinary  temperatures  is  converted  into  cal- 
cium chloride  (CaClg)  by  free  and  combined  HCl,  whereas  it  is 
not  changed  by  acid  phosphates.  The  difference  in  the  acidity 
before  and  after  adding  CaCOg  will  therefore  give  the  amount  of 
physiologically  active  HCl  (L  +  C),  provided  no  other  free  acids  are 
present,  or  if  they  are  there,  have  previously  been  got  rid  of.  The 
acidity  after  the  addition  of  CaCOg  represents  the  amount  of  acid 
salts  present.  As  it  has  been  found  that  the  same  quantity  of  bi- 
acid-phosphate  requires  twice  as  much  alkah  for  neutralization  in 
the  presence  of  CaClg  as  it  does  when  the  latter  is  absent  (on  ac- 
count of  the  formation  of  monocalcium  phosphate),  and  as  CaClg  is 

stomach  contents  by  which  (a)  the  total  chlorine,  (b)  the  loosely  combined  and  fixed 
chlorine,  and  (c)  the  fixed  chlorides  are  ascertained. 

All  the  procedures,  especially  Nos.  7  and  8,  have  been  frequently  discussed,  and 
have  given  rise  to  many  controversies  which  need  not  be  discussed  here.  Critical 
discussions  of  them  may  be  found  in  Martins  and  Liittke's  monograph,  and  also  in 
Kossler  (Zeitschr.  fiir  physiolog.  Chemie,  Bd.  xvii,  p.  91).  It  has  been  shown  by  a 
number  of  observers,  but  especially  by  Martins  and  Liittke  and  also  by  Sansoni 
(Berl.  Klin.  Wochenschr.,  1892,  No.  43),  that  the  relation  between  free  and  com- 
bined HCl  is  uncontrollably  destroyed  by  evaporation  and  incineration.  Moreover, 
F.  A.  Hoffmann  (Schmidt's  Jahrblicher,  Bd.  ccxxxiii,  p.  268)  maintains  all  methods 
for  estimating  MCI  which  necessitate  evaporation  are  to  be  avoided  because  the  de- 
composition produced  in  the  fluid  by  evaporation  can  not  be  calculated. 


LEO'S  TEST.  51 

formed  in  the  reaction,  it  is  necessary  to  liave  an  excess  of  CaCla 

during  all  the  titrations. 

The  method  is  carried  out  as  follows  :  i^fter  removing  and  estimating 
any  organic  acids  which  may  be  present  {vide  supra),  5  c.  c.  of  a  concen- 
trated CaCla  solution  are  added  to  10  c.  c.  of  filtered  stomach  contents,  and 
the  acidity  determined  [with  deci-normal  caustic  soda  solution  and  jDhenol- 
pbthalein].  Then  some  chemically  pure  *  powdered  CaCOs  is  thoroughly 
i-ubbed  up  with  15  c.  c.  filtered  stomach  contents  which  have  been  poured 
into  a  dry  glass  beaker  ;  the  mixture  is  then  passed  through  a  dry  filter. 
Ten  c.  c.  of  the  filtrate  are  measured  off,  air  is  blown  through  to  drive  off 
the  COa  which  is  formed,t  5  c.  c.  CaCla  solution  are  added,  and  the  acidity 
is  again  determined.  The  difference  in  the  results  of  the  first  and  second 
titrations  represents  the  physiologically  active  HCl. 

The  fundamental  principle  of  this  method — i.  e.,  that  the  phos- 
phates are  not  acted  upon  by  calcium  carbonate — has  been  verified 
by  many  observers,  among  whom  are  A.  Meyer, :{:  Hoffmann  and 
"Wagner,*  and  Leo  and  Friedheim.  ||  Langermann  ^  has  compared 
this  test  with  several  others,  and  has  obtained  fairly  good  results. 
Later  investigations  of  Kossler^  have  shown  that  the  experimental 
error  with  solutions  of  HCl-peptones  and  of  albumen,  and  with  the 
small  quantities  of  phosphates  which  are  j)resent  in  the  stomach 
contents,  are  very  slight  (between  1  to  3  per  cent.  HCl),  and  that 
the  results  obtained  are  sufficiently  accurate  for  clinical  purposes. 
I  fully  agree  with  Kossler,  since  for  practical  purposes  it  is  imma- 
terial whether,  in  a  given  case,  we  find  2*5  or  2*58  per  mille  HCl, 
which  is  what  an  error  of  -|-  3*24  would  be  equivalent  to. 

Liittke's  Method. — This  is  based  on  Yolhard's  well-known 
method,  the  principle  of  which  is  that  all  combinations  of  chlorine 
are  converted  by  silver  nitrate  into  silver  chloride.  The  latter  is 
titrated  according  to  the  usual  methods.     Therefore,  if  the  total 

*  CaCOs  is  chemically  pure  when  red  litmus  is  not  blued,  after  rubbing  some  of 
it  up  with  water,  and  when  the  addition  of  sulphuric  acid  to  a  solution  of  it  in 
HCl  does  not  cause  a  precipitate. 

f  This  is  best  done  with  the  double  bulb  of  a  spray  apparatus.  We  detach  the 
double  bulb  and  the  rubber  tube,  and  insert  a  small  piece  of  glass  tubing  into  the 
open  end  of  the  latter. 

X  A.  Meyer,  Ueber  die  neuesten  Methoden,  etc.     Tnaug.  Dissert.,  Berlin,  1890. 

#  Hoffmann  and  Wagner.     Centralblatt  fur  klin  Med.,  1890,  No.  40. 
II  Leo  und  Friedheim.     Pfliiger's  Archiv,  Bd.  xlviii,  p.  614. 

^  Langermann.     Virchow's  Archiv,  Bd.  cxxviii,  p.  408. 
()  Kossler.    Zeitschr.  fur  physiolog.  Chemie,  Bd.  xvii,  p.  91. 


52  DISEASES  OP  THE  STOMACH. 

chlorine  is  first  determined,  and  then  tlie  amount  of  chlorine  after 
incineration,  the  difference  in  the  results  of  the  two  estimations  will 
give  the  amount  of  physiologically  active  HCl  (L  -|-  C).  If  L  has 
been  determined  according  to  Mintz's  method,  then  (L-f-  C)  —  L  =  C 
— ^i.  e.,  the  loosely  combined  HCl. 

For  the  method  the  following  solutions  are  needed : 

1.  Deci-normal  silver  nitrate  solution,  17  grammes  AgNOa  to  the 
litre,  and  containing  an  excess  of  nitric  acid,  so  that  1  c.  c.  exactly  equals 
1  c.  c.  deci-normal  HCl  solution — ^i.  e.,  0"00365  HCl, 

2.  Liquor  ferri  tersulphatis  (U.  S.  Ph.).* 

3.  Deci-normal  ammonium  sulphocyanate  solution,  containing  7'6 
grammes  of  the  salt  to  the  litre,  t 

The  silver  which  is  left  over  after  the  formation  of  silver  chloride 
forms  silver  sulphocyanate  on  the  addition  of  the  ammonium  sulpho- 
cyanate solution.  As  soon  as  all  the  silver  sulphocyanate  has  been 
formed,  the  solution  assumes  a  blood-red  color,  due  to  the  iron  sulpho- 
cyanate. 

(a)  Estimation  of  the  Total  Chlorine. — The  procedure  is  carried  out 
as  follows : 

Ten  c.  c.  of  the  well-shaken  unfiltered  or  filtered  stomach  contents  are 
poured  into  a  graduated  100  c.  c.  flask ;  the  small  flask  in  which  the 
stomach  contents  have  been  measured  must  be  washed  out  with  water 
once  or  twice.  Then  20  c.  c.  of  the  deci-normal  AgNOs  solution  are  added  ; 
the  mixture  is  shaken  and  allowed  to  stand  for  ten  minutes. 

The  addition  of  5  to  10  drops  of  potassium  permanganate  solution 
(1  to  15)  will  decolorize  the  stomach  contents  if  they  are  strongly  tinged ; 
but  this  is  unnecessary  in  the  majority  of  cases.  The  permanganate  is 
not  to  be  added  until  all  the  chlorine  has  combined  with  the  silver, 
otherwise  it  will  act  upon  the  HCl  so  that  the  free  chlorine  will  be  set  free, 
which  will  then  evaporate  and  render  the  results  of  the  analysis  doubtful. 

If  the  decolorization  has  been  effectual  water  is  added  up  to  100  c.  c, 
the  mixture  is  shaken,  and  filtered  through  a  dry  filter  into  a  dry  vessel. 
Fifty  c.  c.  of  the  filtrate  are  then  titrated  with  deci-normal  ammonium 
sulphocyanate  solution. 

The  total  chlorine  is  calculated  as  follows :  The  number  of  c.  c.  of 
ammonium  sulphocyanate  solution  used  is  multiplied  by  two,  and  the  sum 
is  subtracted  from  the  number  of  c.  c.  of  silver  used  (20  c.  c). 

(&)  Estimation  of  the  Chlorides. — Ten  c.  c.  of  the  well-shaken  or  fil- 
tered stomach  contents  are  evaporated  to  dryness  in  a  platinum  dish  over 
a  water  bath.     Instead  of  a  platinum  dish  we  may  use  an  asbestos  plate 

*  17'5  grammes  AgNOg  are  dissolved  in  about  900  c.  c.  25  per  cent,  nitric  acid 
solution,  and  50  c.  c.  hq.  ferri  tersulphatis  are  then  added  ;  water  is  then  added  up 
to  one  litre,  and  is  exactly  adjusted  to  deci-normal  HCl  solution. 

f  Eight  grammes  ammonium  sidphocyanate  are  dissolved  in  one  litre  of  water, 
and  the  titration  point  adjusted  to  the  above-described  silver  solution.  Thus,  for 
example,  if  9'7  c.  c.  ammonium  sulphocyanate  solution  were  used  for  10  c.  c.  silver 
solution,  then  970  c.  c.  of  this  solution  must  be  diluted  to  1,000  c.  c. 


LtTTKE'S  TEST.  53 

which  is  not  too  thick,  and  which  is  heated  by  a  gas  flame  or  alcohol 
lamp.  In  this  way  the  evaporation  takes  place  quickly,  care  being  taken 
that  there  is  no  loss  of  the  fluid  by  splashing. 

The  residue  left  after  evaporation  is  burned  over  an  open  flame  until 
the  residue  no  longer  burns  with  an  illuminating  flame.  Too  strong  and 
too  prolonged  burning  is  unnecessary,  and  is  to  be  avoided  because  the 
chlorides  are  volatilized  by  too  high  a  temperature. 

The  residue  left  after  combustion  is  rubbed  up  with  moistened  charcoal 
by  means  of  a  glass  rod,  and  is  then  dissolved  out  with  about  100  c.  c.  of 
water,  and  the  fluid  is  then  filtered.  Experience  has  shown  that  this 
amount  of  water  is  sufficient  to  completely  dissolve  out  the  charcoal. 
But  if  we  are  in  doubt  whether  all  the  chlorides  have  been  washed  out  we 
may  add  a  drop  of  silver  solution  to  a  few  drops  of  the  last  portion  of  the 
filtrate.  Any  turbidity  will  indicate  the  presence  of  chlorine,  and  will 
necessitate  further  washing. 

The  total  filtrate  is  then  poured  into  a  beaker,  10  c.  c.  deci-normal  silver 
solution  are  added,  and  titration  carried  out  with  the  deci-normal  am- 
monium sulphocyanate  solution. 

The  amount  of  the  combined  chloride  is  obtained  by  subtracting  the 
number  of  c.  c.  of  ammonia  sulphocyanate  solution  used  from  the  amount 
of  silver  solution  employed  (10  c.  c). 

The  difference,  a— 6,  multiplied  by  0-0365,  will  give  directly  the  per- 
centage of  the  physiologically  active  HCl. 

But  even  this  method,  whicli  at  first  glance  seems  perfect,  is 
not  infallible,  in  spite  of  the  fact  that  Yolhard's  method,  which  is 
much  simpler  and  rapid  than  would  appear  from  the  above  descrip- 
tion, has  been  shown  by  chemists  to  be  absolutely  reliable. 
Kossler  *  has  called  attention  to  the  fact  that  in  the  presence  of 
calcium  and  phosphorus  compounds,  the  amount  of  chlorides  (F) 
must  be  too  low,  because  in  the  decomposition  f  free  HCl,  which  is 
volatilized  during  the  evaporation,  is  set  free.  The  amount  of 
physiologically  active  HCl  will  therefore  be  too  high,  because  calcium 
and  phosphoi'us  compounds  are  always  present  in  the  stomach  con- 
tents after  the  test  breakfast.  Another  source  of  error  may  arise 
from  the  presence  of  ammonium  chloride  (KH4CI)  in  the  stomach 
contents.  Even  Bidder  and  Schmidt  found  as  much  as  0*47  per 
mille  JSrH4Cl  in  the  gastric  juice  (containing  no  saliva)  of  dogs, 
although  they  state  that  there  is  no  I^H4C1  in  the  gastric  juice 

*  Loc.  cit. 

t  CaCU  +  KHaPO*  =  CaHP04  +  KCl  +  HCl.  And  SCaClj  +  2KH2PO4  =  Ca 
(P04)2  +  2KC1  +  2HC1.  Kossler's  experiments  show  that  this  loss  may  amount 
to  about  25  to  40  per  cent. 


54  DISEASES  OF  THE  STOMACH. 

(containing  no  saliva)  of  human  beings.*  Leo  f  also  found  only 
traces  of  ammonia  in  human  stomach  contents  with  tests  made  for  this 
purpose  with  Schlosing's  method ;  but  Rosenheim  :{:  states  that  with 
this  method  he  could  demonstrate  ammonia  in  such  quantities  that 
about  10  23er  cent  of  the  HCl  present  in  the  filtrate  of  the  stomach 
contents  examined  must  have  been  thus  combined.  Inasmuch  as 
ammonia  does  not  occur  preformed  in  the  food,  its  presence  can  only 
be  traced  to  the  secretion  of  the  rennet  glands  or  to  putrefaction  of 
the  albumens.  At  all  events,  the  formation  of  ]N'H4C1  renders 
part  of  the  physiologically  active  HCl  inert,  which,  as  may  be 
readily  perceived,  would  be  considered  active  in  Liittke's  method — 
i.  e.,  the  factor  C  would  be  about  10  per  cent  too  high. 

These  reasons  may  perhaps  explain  why  in  Martins  and  Liittke's 
analyses  the  amount  of  HCl  coincides  so  surprisingly  frequently 
with  the  total  acidity  ;  this  would  leave  no  room  for  other  acids  or 
salts  which  in  my  experience  are  always  found  in  the  stomach 
contents. 

However  this  may  be,  it  is  evident  that  Liittke's  method  is  not 
free  from  objections ;  furthermore,  another  disadvantage  is  that  it 
needs  too  many  titrations  and  also  combustion.  As  in  the  method 
of  Leo,  the  free  HCl  must  be  determined  by  a  separate  analysis 
with  Mintz's  method.  JSTevertheless  Liittke's  method  is  to  be  rec- 
ommended because  of  its  relative  sunplicity  and  the  reduction  of 
errors  to  the  lowest  possible  degree. 

Quantitative  Estimation  of  Lactic  Acid. — After  having  ascer- 
tained the  acidity  of  10  c.  c.  of  stomach  contents  they  are  repeat- 
edly shaken  up  with  a  large  quantity  (100  to  150  c.  c.)  [  §  iij-v]  of 
ether,  and  the  acidity  of  the  residue  left  after  the  removal  of  the 
ether  is  determined.  Multiphcation  of  the  difference  of  the  two  re- 
sults by  0*09  will  give  the  approximate  percentage  of  lactic  acid 
which  is  sufficiently  accurate  for  practical  purposes. 

To  carry  out  this  test  it  is  essential  that  volatile  fatty  acids,  es- 
pecially butyric  acid,  be  absent.  Their  presence  may  be  ascertained 
by  pouring  some  stomach  contents  into  a  test  tube  or  a  small  flask, 

*  See  Ewald.     Klinik,  etc.,  I.  Theil,  3te  Auflage,  p.  81. 
f  Leo.     Deutseh.  med.  Wochenschr.,  1891,  No.  41. 
X  Rosenheim.     Centralbl.  fiir  klin.  Med.,  1893,  No.  39. 


QUANTITATIVE  ESTIMATION  OF  LACTIC   ACID.  55 

a  piece  of  moistened  sensitive  blue  litmus  paper  being  placed  in  the 
neck  of  the  tube.  On  heating,  if  volatile  fatty  acids  are  present, 
they  will  escaj)e  with  the  watery  vapor  and  will  redden  the  htmus 
paper.  If  any  fatty  acids  be  found  they  must  be  removed  by  a 
preliminary  boihng ;  the  boihng  is  kept  up  until  the  litmus  paper 
is  no  longer  reddened,  the  water  lost  by  evaporation  being  re- 
placed. 

[Boas  *  has  given  us  what  are  undoubtedly  the  most  accurate 
methods  for  both  the  qualitative  and  quantitative  tests  of  lactic  acid  ; 
but  for  clinical  purposes  they  are  too  delicate,  since  it  has  been 
shown  that  even  some  of  the  reagents  employed  may  simulate  the 
reaction  given  by  decomposition  products  of  lactic  acid.f 

The  principle  of  the  tests  is  this :  When  lactic  acid  is  slowly  and 
carefully  heated  with  oxidizing  agents,  it  sphts  up  into  formic  acid 
and  acetic  aldehyde.  The  presence  and  amount  of  the  latter  sub- 
stance can  be  ascertained  by  many  tests,  of  which  the  iodoform 
test  is  the  best  both  for  quahtative  and  quantitative  purposes.  The 
oxidizing  agent  used  is  potassium  permanganate  and  sulphuric  acid. 
If  the  aldehyde  is  then  conducted  into  an  alkaline  solution  of 
iodine,  iodoform  is  formed.  Under  proper  precautions  a  given 
quantity  of  aldehyde  decomposes  a  given  proj)ortion  of  the  iodine 
solution,  and  hence  the  amount  of  the  former  can  be  determined. 
Ketone  and  alcohol,  which  give  the  same  reaction,  are  removed  by 
boiling  the  fluid  to  be  examined  to  a  sirupy  consistency.  Carbo- 
hydrates heated  with  oxidizing  agents  also  give  off  aldehyde,  so 
that  the  lactic  acid  must  first  be  extracted  with  ether.  The  test 
meal  used  for  this  method  is  Boas's  oatmeal  soup.]  :]: 

Quantitative  analyses  of  the  fatty  acids  will  scarcely  ever  be  re- 
quired in  ordinary  practice.  They  can  only  be  performed  after 
repeated  extraction  with  ether  or  by  distillation. 

Quantitative  Estimation  of  Acid  Salts. — This  is  obtained  by  sub- 
tracting from  the  total  acidity  the  acidity  which  is  obtained  in 
Leo's  method  after  adding  CaCOg.     Inasmuch  as  most  of  the  acid 

*  [Boas.     Loc.  cit.,  p.  179.     Friedenwald.    Loc.  cit. — Ed.] 

f  [Langguth.     Loc.  cit. — Ed.] 

X  [Boas's  oatmeal  soup  consists  of  a  tablespoonful  of  oatmeal  to  a  quart  of  water 
■which  is  boiled  down  to  a  pint.     Salt  may  be  added  to  suit  the  taste.     The  advan- 
tage of  this  meal  is  that  it  does  not  contain  any  lactic  acid  or  lactates. — EiD,'\ 
5 


56  DISEASES   OF   THE  STOMACH. 

compoimds  consist   of   phosphates  the  difierence  must  be  divided 
bv  two  (see  p.  50). 

From  the  methods  of  analyses  described  above  we  may  con- 
Btnict  the  following  schema  for  the  routine  quantitative  examination 
of  stomach  contents : 

Stomach  Contents  obtained  One  Hour  after  Test  Breakfast. — 
Color,  hght  yellow ;  on  filtration,  a  clear  yellow  filtrate  is  obtained ; 
a  homogeneous  residue  is  left  upon  the  filter. 

Reaction  to  litmus,  acid. 

Tropseolin  test,  dark  brown. 

Congo-red  test,  blue. 

Giinzburg's  or  Boas's  test,  carmine  red. 

Uffelmann's  test,  doubtful. 

Butyric  acid,  negative. 

Estimation  of  HCl,  Leo's  method. 

1.  Total  acidity  (A)  =  55. 

2.  Acidity  after  extraction  with  ether  (the  ethereal  extract  gives 
a  positive  reaction  with  Uffelmann's  test)  =  46.  Lactic  acid  there- 
fore =  0"018  per  cent. 

3.  Acidity  after  adding  CaClg  =  56. 

4.  Acidity  after  adding  CaCOs  =  16 — i.  e.,  corresponds  to  acid 
salts. 

6.  Therefore  acidity  due  to  free  acids  =  40. 
From  this  subtract  the  amount  represented  by  lactic  acid  1)  —  2) 
— i.  e.,  55  —  46  =  9.     Therefore 

6.  Acidity  of  physiologically  active  HCl  (L  +  C)  =  31  =r  0*113 
per  cent  HCl. 

7.  Acidity  of  free  HCl  (L)  by  Mmtz's  method  =  14  =  0-05  per 
cent  HCl.     Therefore  combined  HCl  (C)  =  0-063  per  cent. 

It  is  self-evident  that  if  we  only  care  to  ascertain  the  amount  of 
HCl  the  method  may  be  much  simplified  by  adding  the  CaCOg 
directly  to  the  residue  left  after  the  extraction  with  ether.  Fur- 
thermore, when  fatty  acids  are  present,  they  are  to  be  removed  as 
already  stated,  the  acidity  must  be  determined  after  their  removal, 
and  the  amount  subtracted  from  the  results  obtained  in  5). 

It  ^viU  thus  be  seen  that  an  exact  quantitative  analysis  of  the 


VALUE   OF  QUANTITATIVE  ANALYSES.  57 

Btomach  contents  requires  quite  a  little  time  and  work.  Tlie  ques- 
tion naturally  arises,  do  the  results  obtained  pay  one  for  Ms  trouble, 
or,  in  other  words,  could  we  not  obtain  practical  results  for  clinical 
purposes  in  some  simpler  way  i  Disregarding  all  abnormal  mix- 
tures of  acids,  we  may  encounter  one  of  two  varieties  of  cases  :  in  the 
one  free  HCl  has  been  secreted  and  we  may  do  what  was  formerly 
generally  done — namely,  conTert  the  total  acidity  clinically  into  that 
of  the  physiologically  active  HCl ;  we  need  only  bear  in  mind  that 
this  is  absolutely  too  high  on  account  of  the  presence  of  the  acid 
phosphates.  In  the  other  case  no  free  HCl  has  been  secreted ;  here 
large  quantities  of  organic  acids  are  usually  present,  and  the  ques- 
tion arises  whether  any  HCl  at  all  has  been  secreted.  For  this  pur- 
pose we  must  resort  to  one  of  the  above  methods,  which,  for  this 
purpose,  are  much  simplified  because  it  is  unnecessary  to  estimate 
the  quantity  of  free  HCl,  and  because  it  is  immaterial  whether  the 
analytical  error  of  a  few  milligrammes  or  centigrammes  is  made. 
We  only  want  to  know  whether  the  mucous  membrane  is  still  able 
to  pour  forth  any  secretion,  and,  if  so,  to  gaiu  a  rough  idea  to  what 
extent.* 

Hence  my  own  opinion  is  that  Leo's  method  is  the  best  one  for 
clinical  purposes.     [Topfer's  method  also  promises  to  be  valuable 


*  An  approximate  estimation  of  the  looselj  combined  HCl  maj  also  be  rela- 
tively easily  and  rapidly  obtained  -with.  Sjoqrist's  method.  Ten  c.  e.  gastric 
juice  are  evaporated  after  adding  a  tip  of  a  knifebladefnl  of  barium  carbonate  and 
incinerated,  care  being  taken  lest  the  temperature  be  too  high ;  the  ash  is  extracted 
■with  water  and  filtered  To  the  filtrate,  which  is  as  clear  as  water  and  which  con- 
tains any  HCl  which  may  be  present  as  barium  chloride,  a  few  drops  of  concen- 
trated soda  solution  are  added.  If  the  fluid  remains  clear,  HCl  is  absent;  if  it  is 
present,  the  fluid  will  assume  a  whitish  turbidity  or  will  throw  down  a  white  pre- 
cipitate of  carbonate  of  baryta,  from  the  amount  of  which  we  may  at  once  ioier 
what  the  quantity  of  the  loosely  combined  HCl  might  be. 

If  it  could  be  proven  that  after  a  definite  test  meal  of  constant  weight  the 
amoimt  of  loosely  combined  HCl  would  always  be  uniform,  we  could  follow  a  sug- 
gestion of  Biedert  (quoted  by  Langermann.  loc.  cifX  to  add  deci-normal  HCl  until 
free  HCl  appears :  then  by  subtracting  the  amount  of  deci-normal  HCl  used  from 
the  known  amount  of  HCl  necessary  for  saturation  of  the  definite  test  meaL  we 
could  estimate  the  amount  of  loosely  combined  HCl.  But  it  is  evident  that  such  a 
constant  value  does  not  exist,  because  the  quantity  of  swallowed  or  secreted  mucus 
iu  the  stomach  is  always  variable,  and.  furthermore,  because  the  quantity  of  HCl 
combined  with  albumen,  aibumoses.  and  peptones  must  then  always  be  constanr_ 
and  these  latter  substances  must  always  be  present  in  that  amount  at  a  definite 
period  of  digestion. 


58 


DISEASES  OF  THE  STOMACH. 


where  the  saving  of  time  is  important.     Hoppe-Seyler,  De  Jong  and 
Friedenwald  *  commend  it  highly.] 

For  the  sake  of  comparison  I  have  charted  a  series  of  curves 
(Fig.  5)  of  the  total  acidity  calculated  as  HCl,  the  total  HCl  accord- 
ing to  Leo's  method,  the  total  HCl  according  to  Liittke's  method, 
and  the  free  HCl  according  to  Mintz's  method.     They  were  ob- 


0 

1 

2                         3 

HOORS 

4 

5 

3                         7                         8                          9 

O.40  - 

0.35 

^ 

. 

i-z-^s 



_, 

---^ 

1.                       0. 

0.30  _ 

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t:""~S-^^   +      II 

z 

--^  ''•. 

"V 

/'"^ 

>- ^^      s 

z  : 

-/-<>-  - 

s 

/' 

it           S^           >v 

^z 

/t^. 

•V 

0.25  " 

=.'^ 

rv 

' 

l-"^            <*~ 

1 , 

55     IT 

V 

*^^-F 

- 

^-- 

"    >ps^   ^^^-i    - 

^j 

.<  ■ 

-  s^A 

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0.20 ; 

— i--^- 

l_L.V=--^^-^  — - 

q4^ 

- 

-- 

fr 

i     -^-     - 

.■^ 



- 

~ " 

1 »s;--D =0- 

-     J 

^ 

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-,t 

t                       : 

S-L 

0.15  " 

t^^ 

-^2          t- 

/ 

-      t        - 

* 

.ay        L 

r 

0.10 

• 

~1r~k. '^^ 

-.        'A 

.hSf-^L 

0.06 

' 

0.01   " 

.« 

_ 

_, 

Fig.  5. — a,  HCl  calculated  from  acidity ;  S,  total  HCl  calculated  according  to  Leo's  method ; 
c,  total  HCl  calculated  according  to  Liittke's  method ;  d,  free  HCl  calculated  according 
to  Mintz's  method. 

tained  from  the  stomach  contents  of  a  woman  upon  whom  gastros- 
tomy had  been  performed  on  account  of  a  cicatricial  stenosis,  of  the 
oesophagus  after  an  ulcus  oesophagi ;  hence  at  any  time  stomach 
contents  could  be  readily  obtained  through  the  gastric  fistula.f  The 
stomach  was  affected  only  in  so  far  that  if  food  remained  unduly 
long  in  it  hyperchlorhydria  would  occur ;  this  very  fact  enables  us 
to  follow  the  course  of  the  secretion  of  HCl  unusually  well.  The 
meal  given  for  these  experiments  consisted  of  500  c.  c.  [O  j]  tea,  two 
eggs,  two  zwieback,  200  c.  c.  [f  5  vjf  ]  milk,  and  50  grammes  [  §  j  f  ] 
meat  powder.  Free  HCl  did  not  appear  till  after  one  hour  and  a 
half.     Lactic  acid  was  only  present  in  traces  at  the  beginning. 

*  [Hoppe-Seylcr.     Miinchener  med.  Wochenschr.,  1895,  No.  50.     De  Jong,  Boas's 
Arch.  Bd.  ii.  Heft,  i.     Friedenwald,  N.  Y.  Med.  Record,  Apr.  6,  1895.— Ed.J 
t  Ewald.    Zeitschr.  fiir  klin.  Med,,  Bd.  xx,  Heft  4-6. 


VALUE   OF   QUANTITATIVE  ANALYSES.  59 

These  curves  show,  as  has  already  been  said,  that  the  total  acid- 
ity may  be  calculated  as  HCl  without  any  great  error,  especially  if 
at  the  same  time  the  quantity  of  free  HCl  has  also  been  determined. 
The  differences  in  the  two  results  would  then  about  represent  the 
combined  HCl,  provided,  of  course,  that  the  quantity  of  acid  salts 
is  small  and  organic  acids  have  been  removed.  Rosenheim  *  has 
also  urged  that  the  determinations  of  the  total  acidity  and  of  the 
amount  of  free  HCl  are  perfectly  sufficient  for  all  practical  purposes. 
I  would  like  to  erase  the  word  "  perfectly  "  from  this  sentence,  be- 
cause the  numerous  cases  without  free  HCl  would  then  be  insuffi- 
ciently regarded ;  yet  for  general  use  in  all  cases  where  free  HCl  is 
present  this  simplified  procedure  will  suffice,  for  in  the  majority  of 
these  cases  the  estimation  of  the  quantity  of  the  loosely  combined' 
HCl  is  relatively  unimportant.  Thus  in  the  great  majority  of  cases 
the  elaborate  quantitative  determinations  of  acidity  would  be  re- 
duced to  a  few  titrations  which  take  up  very  Kttle  time. 

*  Rosenheim.  Ueber  die  practische  Bedeutung  der  quantitativen  Bestimmung 
der  freien  Salzsaure  im  Mageninhalt,  Deutsch.  med.  Wochenschr.,  1892,  Nos.  13 
and  14. 


CHAPTEK  II. 

METHODS    OF    EXAMINATION  {continued). DETERMINATION   OF   THE   DI- 
GESTION   OF    ALBUMEN   AND    STAKCH. ABSORPTION   AND    MOTILITY. 

THE   TECHNIQUE    OF   THE    EXAMINATION    OF   THE    STOMACH. 

The  essence  of  the  digestion  of  albumen  consists  in  tlie  well- 
known  transformation  of  the  various  kinds  of  this  substance,  of 
which  I  shall  only  mention  the  more  important  varieties — egsj, 
serum,  and  plant  albumen,  fibrin,  and  casein — into  a  soluble  and 
easily  diffusible  form,  peptone.  In  another  place*  I  have  already 
given  an  exact  description  of  these  changes,  and  now  I  shall  restrict 
myself  to  the  practical  deductions  from  the  facts  known  to  us.  It 
is  well  known  that  between  albumen  at  the  beginning  and  peptone 
at  the  end  of  the  process  of  albuminous  digestion  there  exist  certain 
intermediate  bodies  which  are  collectively  known  as  the  albumoses. 
Of  these  we  are  concerned  only  with  syntonin,  the  product  of  neu- 
tralization, and  propeptone  or  hemialbumose.  ]^ow,  the  question 
arises.  What  significance  have  these  bodies  in  the  processes  of  diges- 
tion, and  by  what  tests  may  they  be  recognized  ? 

1.  Temperature. — Fluid  albumen  and  syntonin  coagulate  on 
warming — i.  e.,  heating  to  about  ^70°  C.  [158°  F.].  Propeptone  and 
peptone  are  not  coagulated  by  heat.  If  propeptone  is  precipitated 
from  its  solutions  in  the  cold  and  is  then  heated,  the  precipitate  re- 
dissolves,  but  is  again  deposited  on  cooling.  Temperature  has  abso- 
lutely no  influence  on  peptone. 

2.  Biuret  Reaction. — If  cupric  sulphate  is  added  to  propep- 
tone and  peptone  in  an  alkaline  solution,  an  intense  purple-red 
color  is  observed,  the  so-called  biuret  reaction.  If  caustic  pot- 
ash and  dilute  cupric  sulphate  are  added  to  ordinary  albumen  and 

*  Ewald.  Klinik  der  Verdaimngskrankheiten,  I.  Theil,  3te  Auflage,  p.  93,  etc. 
[See  also  Chittenden's  Cartwright  Lectures  on  Digestive  Proteolysis,  New  Haven, 
1895.  This  work  contains  an  elaborate  and  masterly  description  of  this  entire  sub- 
ject.—Ed.] 

60 


REACTIONS   OF   ALBUMEN,  ETC.  01 

Byntonin  without  warming,  a  more  or  less  marked  bluisli-violet  color 
is  struck,  wbicli  at  all  events  may  often  be  confounded  witb  the 
biuret  reaction.  To  a  solution  of  peptone  add  some  caustic  potash, 
and  then  a  little  dilute  cupric  sulphate ;  a  deep  purple-red  color  will 
be  obtained  which  is  distinctly  different  from  this  bluish-violet  color 
obtained  in  a  similar  way  with  a  solution  of  pure  albumen.  The 
same  is  true  of  propeptone,  as  can  be  shown  with  a  solution  of  meat 
peptone.  When  the  quantity  of  peptone  or  propeptone  is  small, 
the  copper  solution  must  be  diluted  to  a  very  pale  blue  and  must  be 
added  drop  by  drop  ;  a  rose-red  zone  will  appear  about  the  drops  as 
they  fall  into  the  solution ;  this  color  will  then  gradually  drffuse 
through  the  solution. 

3.  Precijpitation. — Albumen  and  syntonin  are  precipitated  by 
saturated  solutions  of  sulphate  of  soda  or  common  salt  in  an  acetic- 
acid  solution,  hot  or  cold.  Syntonin  is  precipitated  from  acid  solu- 
tions as  soon  as  it  is  neutralized.  Propeptone  in  neutral  solution 
is  precipitated  by  a  saturated  solution  of  common  salt  or  rock 
salt  on  adding  strong  acetic  acid;  it  is  soluble  when  heated. 
However,  a  portion  remains  in  solution,  and  can  only  be  precipi- 
tated by  the  addition  of  ammonium  sulphate  in  substance  or  in 
concentrated  solution.  Peptones  are  not  precipitated  by  the  above 
nor  by  the  following  reagents  which  throw  down  albumen,  syntonin, 
and  propeptone :  cold  or  warm  nitric  acid,  acetate  of  lead,  acetic 
acid  with  f  errocyanide  of  potash,  metaphosphoric  acid,  ammonium 
sulphate.  The  behavior  of  the  above-mentioned  substances  may  be 
seen  at  a  glance  in  the  following  tables  : 

^         ■,,-,■,,  f  .  ,1  {.  Precipitated  by  saturated  solution  of  sulphate 

Coagulated  by  heat ;  \  Albumen.      \      ^^  ^^^^  ^^  ^^^^^^^^  ^^^^  ^^^  ^^^^.^  ^^.^^  ^^^^ 

no  biuret  reaction.  /  Syntonin.      /  „ 

V.    •'  I      or  warm. 

Not  coagulated    by  i  pj.„„  „<.        j  Precipitated    cold    by  saturated    solution  of 

heat ;  biuret  reae-  \  '  \      common  salt  and  strong  acetic  acid. 

tion.  '  Peptone. 

'Nitric  acid,  acetic  acid. 

Acetic  acid  and  ferrocyanide  of  potash. 

Acetate  of  lead. 

Metaphosphoric  acid. 

Ammonium  sulphate. 

Mercuric  chloride. 

Phosphotungstic  acid. 

Phosphomolybdic  acid,  v  Precipitate  peptone. 

Tannin. 

Mercuric  iodide. 


Precipitate  albumen 
syntonin,  and  pro- 
peptone. 


62  DISEASES  OF  THE  STOMACH. 

JlsTow,  what  are  the  practical  deductions  from  these  results  ? 

If  gastric  juice  containing  pepsin  and  hydrochloric  acid  be  al- 
lowed to  act  on  albumen,  after  a  certain  time  the  mixture  ought 
to  contain  the  various  modifications  of  albumen,  and,  according  to 
the  nature  and  strength  of  the  gastric  juice,  some  or  all  of  them  ought 
to  be  present.  The  results  of  such  an  examination  will  give  us  an 
indication  of  the  intensity  of  the  digestive  processes  in  the  stomach. 
Accordingly,  we  first  test  whether  the  stomach  contents  are  coagu- 
lable  by  heat.  If  they  are,  albumen  or  syntonin,  or  both,  may  be 
present ;  if  not,  we  may  find  propeptone  or  peptone.  If  the  reac- 
tion is  acid,  and  coagulation  occurs  on  heating,  we  must  neutralize. 
Should  a  preci]3itate  be  thrown  down,  it  is  syntonin.  If  this  is  fil- 
tered out  and  an  equal  quantity  of  concentrated  common-salt  solu- 
tion is  added  to  the  filtrate,  and  then  acidulated  with  acetic  acid,  any 
precipitate  thrown  down  which  is  redissolved  on  heating  is  due  to 
proj)eptone,  and  the  biuret  action  must  be  positive.  The  latter  pre- 
cipitate is  also  removed  by  filtration ;  the  filtrate  is  treated  with 
acetic  acid  and  f  errocyanide  of  potash  ;  if  no  precipitate  is  obtained, 
and  if  the  biuret  test  is  positive,  and  if,  furthermore,  precipitates 
are  thrown  down  by  tannin  or  the  salts  of  the  heavy  metals,  or  by 
phosphotungstic  acid,  etc.,  then  peptone  is  present. 

Such  would  be  the  method  of  conducting  an  examination.  But 
the  question  naturally  arises.  What  is  the  practical  value  of  such  a 
demonstration  of  the  various  transformation  products  of  the  diges- 
tion of  albumen,  and  what  conclusions  can  be  drawn  in  regard  to 
the  pathology  of  the  cases  in  question  ? 

It  is  a  peculiar  fact  that  as  soon  as  the  digestion  of  albumen  has 
begun  as  the  result  of  the  action  of  pepsin  and  hydrochloric  acid, 
the  biuret  reaction  may  be  obtained  in  a  very  short  time.  This  may 
be  due  either  to  propeptone  or  peptone.  I  shall,  therefore,  briefly 
consider  the  relations  of  jpropeptone  to  digestion. 

Is  it  absorbed  as  such,  or  is  it  simply  a  necessary  prehminary 
stage  of  peptone  ?  Concerning  the  former  we  know  nothing ;  of 
the  latter  we  can  at  least  say  that  propeptone  seems  to  be  a  very 
frequent  but  by  no  means  a  constant  transformation  product  in  the 
digestion  of  albumen  by  pepsin  and  hydrochloric  acid.  On  the 
other    hand,   by   the    simple    action    of    hydrochloric    acid    upon 


RELATIONS   OF  PROPEPTONE.  63 

albumen  at  tlie  temperature  of  the  body,  syntonin  as  well  as 
jDropeptone  may  be  obtained.  Since  propeptone  will  give  the 
biuret  reaction  as  well  as  peptone,  tlie  simple  application  of  this 
test,  as  has  been  done  heretofore,  will  give  no  positive  proof  of 
the  presence  of  peptone.  The  best  way  is  to  precipitate  the  pro- 
peptone. 

As  the  result  of  investigations  conducted  in  my  laboratory.  Dr. 
Boas  *  has  shown  that  that  portion  of  propeptone  which  is  precipi- 
tated by  rock  salt  and  acetic  acid  is  absent  in  the  digestion  of  meat, 
but  is  present  in  the  digestion  of  plant  albuminates  and  pure  egg 
albumen.  On  an  ordinary  mixed  diet  the  amount  of  propeptone 
which  is  precipitated,  as  above  stated,  bears  some  relation  to  the 
activity  of  digestion,  so  that  from  the  precipitability  and  amount  of 
propeptone  approximate  conclusions  may  be  drawn  as  to  the  digest- 
ive process.  It  would  be  much  better  if  this  could  be  determined 
from  the  quantitative  analysis  of  the  peptones,  to  which  there  are 
two  objections.  One  is  that  we  do  not  at  present  possess  any  con- 
venient and  sufficiently  accurate  method  for  estimating  the  quantity 
of  peptones,  since,  as  has  been  already  shown,  the  intensity  of  the 
biuret  reaction  is  of  no  use,  because  it  responds  to  both  peptone  and 
propeptone.  Secondly,  as  some  investigations  of  my  own  f  have 
shown,  digestion  in  the  human  stomach  produces  only  a  very  small 
proportion  of  true  peptone,  the  greater  portion  of  the  albumen 
being  converted  into  propeptone  and  the  albumoses  of  Kuhne. 
Hence  under  the  term  "peptone"  are  included  those  products  of 
proteid  digestion  which  are  not  precipitated  by  ammonium  sulphate 
in  neutral  solution,  rock  salt  (or  concentrated  sodium  chloride  solu- 
tion), or  a  saturated  solution  of  common  salt  in  acetic  acid ;  which 
give  the  biuret  reaction  ;  which  remain  in  solution  at  any  tempera- 
ture, and  are  only  precipitated  by  mercuric  chloride,  tannin,  phos- 
photungstic  acid  (phosphomolybdic  acid),  picric  acid,  and  mercuric 
iodide  and  potassic  iodide  solution. 

Hence  it  is  of  considerable  value  to  determine   and    approxi- 


*  I.  Boas.  Beitrage  zur  Eiweissverdauung.  Zeitschr.  fur  klin.  Med.,  Bd.  xii, 
Heft  3. 

t  Ewald  und  Gumlich.  Ueber  die  Bildung  von  Pepton  im  menschlichen 
Magen.     Berl.  klin.  Wocheuschr.,  1890,  No.  44. 


64  DISEASES  OP  THE  STOMACH. 

mately  estimate  not  alone  the  end  products  of  proteid  digestion, 
but  also  the  intermediate  bodies, 

IN^ow,  we  have  found  that  in  an  ordinary  diet,  containing  an 
abundance  of  plant  albuminates,  and  after  the  test  breakfast,  the  di- 
gestion of  albumen  has  progressed  so  far  within  an  hour  that  that 
portion  of  propeptone  which  is  precipitated  by  concentrated  ]^aCl 
solution  and  acetic  acid  is  present  only  in  traces,  or  usually  is  not 
to  be  detected  at  all ;  whereas  in  abnormally  slow  digestion  it  is  still 
abundant  at  that  period.  "We  may  also  approximately  estimate  the 
amount  of  peptone  by  the  intensity  of  the  biuret  reaction  provided 
we  always  use  the  same  quantities  of  stomach  contents,  caustic  pot- 
ash, and  cupric  sulphate,*  and  compare  it  with  the  reaction  given 
with  a  peptone  solution  of  known  strength.  But  it  has  been  ob- 
served that  the  biuret  reaction  is  equally  intense  where  at  the  same 
time  there  is  either  no  propeptone  or  where  the  amount  of  the  lat- 
ter is  very  variable.  In  other  words,  just  as  Cahnf  found  in  the 
digestion  of  meat  in  dogs,  the  formation  of  peptone  remains  at  a 
certain  percentage,  or  is  kept  at  that  figure  by  the  removal  of  the 
peptones  over  that  amount ;  in  such  cases  the  only  guide  to  the 
rapidity  and  amount  of  the  transformation  of  the  albumen  is  the 
amount  of  propeptone  formed  or  still  remaining.  ]^aturally  there 
are  also  cases  in  which  the  peptone  formation  does  not  reach  the 
normal  height,  being  thus  entirely  insufiicient ;  for  this  reason  it  is 
advisable  to  make  the  test  for  propeptone  even  where  the  amount 
of  peptone  is  apparently  normal. 

However,  we  not  infrequently  encounter  cases  in  which  a 
positive  biuret  reaction  is  obtained,  although  no  free  HCl  can  be 
demonstrated.  Further  analysis  will  also  demonstrate  the  absence 
of  propeptone  (as  defined  above) ;  in  other  words,  this  will  show 
that  the  proteid  digestion  is  well  advanced.  How  can  this  be  ex- 
plained, since  we  know  that  peptone  can  only  be  found  in  the  pres- 
ence of  pepsin  and  HCl  ?     There  are  two  possible  explanations. 

*  On  the  addition  of  caustic  potash  many  stomach  contents  turn  yellow.  Spitzer 
has  separated  from  this  a  yellowish-brown  amorphous  substance  which  assumes  an 
onion-red  color  on  the  addition  of  alkalies.  Centralblatt  filr  klin.  Med.,  1891, 
No.  9, 

f  A.  Cahn.  Die  Verdauung  des  Fleisches  im  normalen  Magen.  Zeitschr.  fiir 
klin.  Med.,  Bd.  xii,  Hefte  1  und  2. 


DIGESTION   TESTS.  65 

One  is  tliat  all  HCl  is  not  absent,  but  only  tlie  free  IICl,  and  further 
analysis  will  reveal  the  presence  of  loosely  combined  HCl.  But, 
as  was  demonstrated  many  years  ago  (1882)  by  me,*  and  later  on 
also  by  Salkowski  and  Kumagawa,t  loosely  combined  HCl  and 
pepsin  can  peptonize  albumen,  although  the  action  is  a  very  feeble 
one.  The  other  possibility  is  that  when  all  HCl  is  absent,  large 
quantities  of  lactic  acid  are  always  present ;  in  such  cases  the  lactic 
acid  takes  the  place  of  HCl  in  the  peptonizing  process,  provided 
pepsin  is  still  secreted.  Although  the  presence  of  HCl  always  in- 
dicates that  pepsin  will  be  found,  yet  conversely  the  absence  of  HCl 
does  not  prove  that  pepsin  is  lackmg.  For  it  has  been  proved  by 
the  physiological  experiments  of  Cahn  ^  and  by  an  observation  of 
my  own  #  that  the  secretion  of  pepsin,  at  least  in  small  quantities, 
may  be  independent  of  HCl.  The  presence  of  peptone  in  the 
stomach  contents  can  thus  be  explained  when  there  is  no  physiologi- 
cally active  HCl  (L  +  C),  and  when  the  peptones  have  not  been  re- 
gurgitated from  the  intestines. 

Hence,  for  the  reasons  given  above,  the  estimation  of  peptones 
with  the  biuret  reaction  is  always  doubtful,  and  it  is  much  more 
advisable  to  determine  the  digestive  power  of  the  gastric  juice  by 
the  rapidity  with  which  coagulated  albumen  is  liquefied  (proteo- 
lysis). 

Digestion  Tests. — Coagulated  white  of  egg  is  cut  into  thin  lam- 
ellae with  a  double  section  knife  [Yalentine's  knife],  and  uniform 
disks  are  cut  out  with  a  cork -borer  or  some  similar  instrument  with 
a  round,  hollow  cutting  edge.  [A  short  piece  of  glass  tubing  will 
do.]  By  preserving  these  disks  of  albumen  in  glycerin  they  are 
ready  for  use  at  any  time.  In  order  to  determine  in  a  given  speci- 
men of  stomach  contents  whether  the  pepsin  or  hydrochloric  acid  is 
present  in  too  great  or  too  small  amount,  an  equal  quantity  of  the 
filtered  specimen  is  placed  in  four  small  test  tubes  and  one  or  two 

*  Ewald.    Virchow's  Archiv,  Bd.  xc,  p.  333. 

•f-  Salkowski  und  Kumagawa.  Virchow's  Archiv,  Bd.  cxxii.  See  also  Rosenheim. 
Centralblatt  fiir  klin.  Med.,  1891,  No.  39 ;  and  F.  A.  Hoffmann,  ibid,  No,  43. 

X  Cahn.  Die  Magenverdauung  im  Chlorhunger.  Zeitschrift  fiir  physiol.  Chemie, 
1886,  Bd.  X. 

*  Ewald.  Ein  Fall  von  Atrophic  der  Magenschleimhaut.  Berl,  klin.  Wochen- 
schr.,  1886,  No.  33. 


66  DISEASES  OF   THE  STOMACH. 

disks  of  albumen  put  into  each.  To  the  first  nothing  else  is  added ; 
to  the  second,  enough  hydrochloric  acid  to  make  a  solution  of  about 
0-3  to  0-5  per  cent ;  this  is  accomplished  by  adding  two  drops  of 
hydrochloric  acid  (Ph.  Germ.)*  to  5  c.  c.  [f  3  ji]  of  stomach  con- 
tents. To  the  third  we  add  a  definite  quantity  of  pepsin,  about  0-2 
to  0-5  gramme  [gr,  iij  to  gr.  vijss.]  ;  to  the  fourth  add  both  hydro- 
chloric acid  and  pepsin.  The  test  tubes  are  placed  in  a  warm  cham- 
ber kept  at  about  100°  Fahr. ;  from  time  to  time  we  [shake  the  tubes 
and]  look  to  see  how  far  the  liquefaction  of  the  disks  of  albumen 
has  proceeded.  The  rapidity  of  this  liquefaction  will  at  once  inform 
us  whether  digestion  would  have  occurred  without  having  added 
anything,  or  whether  acid  or  pepsin  or  both  were  necessary.  [Pieces 
of  Merck's  fibrin  may  be  used  instead  of  the  disks  of  albumen.]  In 
this  way  we  can  judge  which  factor  is  at  fault.  But  we  must  not 
forget  that  after  the  amount  of  peptone  has  reached  a  certain  per- 
centage its  further  production  is  retarded,  or  even  suspended,  so 
that  an  apparently  slow  reaction  may  be  really  due  to  a  very  active 
gastric  juice.  In  this,  as  in  all  laboratory  experiments  on  digestion, 
we  must  never  forget  the  great  difference  between  them  and  the 
natural  processes,  and  that  in  our  flasks  and  test  tubes  we  can  never 
imitate  the  absorption  on  the  one  hand,  and  the  removal  to  the  in- 
testines on  the  other,  by  which  the  stomach  strives  to  maintain  a 
fairly  uniform  degree  of  concentration  of  its  contents ;  hence  all  our 
tests  are  fundamentally  deviations  from  ISTature,  and  are  thus  to  a 
certain  degree  pathological. 

The  question  naturally  arises,  Is  it  necessary  to  resort  to  these 
somewhat  inconvenient  digestion  tests,  and  will  it  not  suffice  to  sim- 
ply employ  the  acid  tests,  since  the  rule  is  that  the  secretion  of  HCl 
and  pepsin  run  parallel  courses  ?  Any  one  who  has  done  much  work 
in  stomach  analysis  will  answer  this  question  in  the  affirmative, 
since  there  are  many  stomach  contents  in  which  the  amount  of  free 
HCl  does  not  stand  in  a  direct  relation  to  the  peptic  power,  and,  as 
has  been  shown  above,  proteolysis  may  occur  even  in  the  complete 
absence  of  free  HCl.     Consequently,  as  has  also  been  stated  by 

*  [Acidum  hydrochlorieum  of  the  German  Pharmacopoeia  is  somewhat  feebler 
than  that  of  the  U.  S.  Pharm. ;  the  former  has  25  per  cent  pure  anhydrous  acid,  the 
latter  33  per  cent. — Ed.] 


TESTS   FOR   PEPSIN  AND   RENNET.  67 

Tsclilenoff,*  the  digestive  powers  of  such  stomach  contents  can  only 
be  ascertained  with  the  digestion  tests. 

[For  quantitative  estimation  of  pepsin  Hammerschlag  f  employs 
Esbach's  tubes  (such  as  are  used  for  quantitative  estimations  of  al- 
bumen in  the  urine).  Take  three  portions,  10  c.  c.  ( 3  ^)  each,  of  a 
1-per-cent  solution  of  albumen,  which  is  prepared  by  dissolving  the 
albumen  in  a  0'4-per-cent  HCl  solution;  to  the  first  portion  add 
5  c.  c.  (  o  i)  gastric  filtrate ;  to  the  second  the  same  and  also  0*5 
grammes  (gr.  vijss.)  pepsin  (this  is  the  standard  solution) ;  to  the 
third  only  5  c.  c.  water.  Three  Esbach  tubes  are  respectively  filled 
with  a  portion  of  each  solution  up  to  the  U  mark  on  the  tube,  and 
placed  for  an  hour  in  a  thermostat  at  98°  F.  Then  Esbach's  reagent 
is  poured  into  each  tube  up  to  the  R  mark,  and  the  albumen  pre- 
cipitated as  usual.  After  standing  24  hours  the  amount  of  precipi- 
tated albumen  is  read  ofE  the  scale  on  the  tube.  The  difference  be- 
tween the  first  and  third  tubes  will  give  the  amount  of  digested 
albumen. 

When  we  wish  to  be  absolutely  certain  about  the  absence  of 
pepsin  and  pepsinogen  we  may  use  the  method  proposed  by  Jawor- 
ski.:};  Into  the  empty  stomach  about  200  c.  c.  [  |  vjss.]  of  deci-nor- 
mal  HCl  solution  are  poured  through  a  stomach  tube,  and  aspi- 
rated after  30  minutes.  If  the  fluid  obtained  contains  no  pepsin  we 
may  be  certain  that  no  ferments  are  secreted  by  the  stomach  (Leo). 

These  pepsin  tests  are  only  of  value  in  diagnosticating  total 
atrophy  of  the  stomach,  which  is  the  sole  condition  in  which  the 
ferments  are  absent.*] 

The  gastric  glands  secrete  not  alone  pepsin  but  also  rennet  fer- 
ment (Zabferment),  which  causes  the  coagulation  of  milk.  Its  pres- 
ence may  be  detected  by  taking  a  small  quantity,  10  c.  c.  [f  3  ijss.],  of 
boiled  milk  having  a  neutral  reaction,  and  adding  an  equal  amount 


*  Tschlenoflf.  Aciditat  und  Verdauung.  Schweizer  Correspond.  Blat.,  1891, 
No.  32. 

f  [Hammerschlag.    Internat.  klin.  Rundschau,  1894,  No.  39. — Ed.] 
X  [Jaworski.    Verhandlungen  des  VII.  Congresses  fiir  innere  Med.,  1888,  p.  272, 
— Bd,] 

*  [Oppler  (Centralblatt  fiir  innere  Med.,  February  1,  1896)  has  carefully  studied 
the  relations  cf  pepsin  in  different  diseases  of  the  stomach.  H«  concludes  that  the 
quantitative  estimations  of  pepsin  are  unnecessary. — Ed.] 


68  DISEASES   OP   THE   STOMACH. 

of  carefully  neutralized  filtered  stomach  contents ;  tlie  mixture  is 
then  placed  in  a  warm  chamber  at  100°  Fahr.,  and  after  a  short 
time,  10  to  15  minutes  on  an  average,  the  milk  has  coagulated  and 
separated  into  a  cake  of  casein  and  clear  serum.  [Leo  *  uses  10  c.  c. 
of  raio  milk,  and  only  2  to  5  drops  of  stomach  contents.  On  account 
of  the  relatively  small  quantity  of  the  latter,  neutralization  of  the 
mixture  is  unncessary.  Eaw  milk  is  used  because  it  coagulates  ten 
times  more  rapidly  than  cooked  milk.  With  this  modification  it 
occurs  from  one  minute  to  several  hours  after  being  placed  in  the 
warm  chamber.  Coagulation  by  rennet  produces  the  characteristic 
cake  of  casein  floating  in  clear  serum,  and  is  not  to  be  confounded 
with  the  flaky  or  lumpy  coagulation  by  acids.] 

The  rennet  ferment  or  enzyme  {Labenzym)  exists  also  in  a  pre- 
liminary stage  as  a  pro-enzyme  or  rennet  zymogen  {Labzymogen) ; 
this  itself  has  no  action  upon  milk,  but  by  adding  acids,  especially 
hydrochloric  acid,  and  also  calcium  chloride  while  warm,  it  is  con- 
verted into  the  typical  ferment.  This  will  become  evident  in  the 
filtrate  of  a  gastric  juice  which  either  has  no  spontaneous  coagulat- 
ing action  or  in  which  the  ferment  has  been  destroyed  by  adding  an 
alkaline  carbonate.  If  such  a  filtrate  be  digested  with  dilute  hydro- 
chloric acid,  or  if  a  5-per-cent  calcium-chloride  solution  be  added, 
it  will  curdle  milk.  In  the  stomach,  while  fasting,  and  at  the  be- 
ginning of  digestion,  the  zymogen  is  only  found,  but  later  both  it 
and  the  ferment  are  present.  An  acid  reaction  or  the  presence  of 
free  acid  in  the  original  filtrate  of  the  stomach  contents  is  not  abso- 
lutely necessary  for  the  curdling  action  of  rennet,  since  it  has  been 
demonstrated  when  free  acid  was  absent,  or  even  when  the  reaction 
was  neutral. 

Among  the  various  investigations  on  rennet  in  human  beings 
I  would  call  especial  attention  to  the  works  of  Kaudnitz,  Boas, 
Johnson,  Klemperer,  and  C.  Rosenthal.f 

*  [Leo,     Diagnostik,  etc.,  2te  Aufl.,  1895,  p.  328.— Ed.] 

■)•  Raudnitz.  Ueber  das  Vorkommen  des  Labferments  im  Sauglingsraagen. 
Prager  med.  Wochenschr.,  1887,  No.  24. — Boas.  Labferment  und  Labzymogen  im 
gesunden  und  kranken  Magen.  Zeitschr.  fur  klin.  Med.,  Bd.  xiv,  S.  249.— Johnson. 
Studien  iiber  das  Vorkommen  des  Labferments,  etc.  Ibid.,  S.  240. — Klemperer. 
Die  diagnostischer  Verwerthbarkeit  des  Labferments.  Ibid.,  S.  280. — C.  Rosenthal. 
Ueber  das  Labferment  nebst  Bemerkungen  liber  die  Production  f reier  Salzsaure  bei 
Phthisikern.    Berl.  klin.  Wochenschr.,  1888,  No.  45. 


DIGESTION  OF  STARCH  AND  SUGAR.  69 

[Boas*  has  devised  tests  for  the  quantitative  testing  of  both 
rennet  ferment  and  zymogen.  "  To  test  rennet  ferment  a  portion 
of  the  gastric  filtrate  is  exactly  neutralized,  and  portions  are  diluted 
with  distilled  water  {-^q,  J^-,  ^,  etc.) ;  5  c.  c.  of  each  of  these  por- 
tions are  placed  in  beakers  and  5  c.  c.  of  milk  added  to  each.  The 
mixtures  are  then  placed  in  the  thermostat.  It  can  easily  be  deter- 
mined at  what  dilution  the  ferment  is  no  longer  active. 

"  Kennet  zymogen  is  tested  in  a  similar  way.  A  portion  of  the 
gastric  filtrate  is  made  slightly  alkaline  and  portions  diluted  (y^, 
IT?  ^V?  TS"?  etc.).  To  5  c.  e.  of  each  of  these  portions  1  c.  c.  of  a 
1-per-cent  solution  of  calcium  chloride  and  5  c.  c.  milk.  The  mix- 
tures are  placed  in  the  thermostat  and  the  point  at  which  the  rennet 
zymogen  is  no  longer  active  can  then  be  determined." 

Friedenwald  f  concludes  that  normally  rennet  ferment  may  be 
present  in  dilutions  up  to  -^,  and  the  zymogen  up  to  -j^^.  The 
estimations  are  of  no  value  when  HCl  is  present,  but  may  be  im- 
portant when  free  HCl  is  absent  in  differentiating  cases  of  anachlor- 
hydria  due  to  severe  chronic  gastritis  or  cancer  from  the  cases  of 
nervous  anachlorhydria. 

Diastase  (ptyalin)  is  another  ferment  which  is  constantly  present 
in  the  stomach  contents ;  it  is  derived  from  the  swallowed  saliva  or 
regurgitated  intestinal  contents.  Its  presence  may  be  determined 
by  neutralizing  free  gastric  filtrate  and  adding  a  few  c.  c.  to  an 
equal  quantity  of  a  thin  starch  solution.  The  mixture  is  placed  in 
the  thermostat  for  1  or  2  hours.  The  addition  of  dilute  Lugol's 
solution  will  show  whether  all  the  starch  has  been  converted  into 
sugar,  or  whether  the  intermediate  dextrine  are  present.] 

Digestion  of  Starch  and  Sugar. — It  will  be  remembered  that  in 
the  organism  starch  is  converted  into  grape  sugar  (dextrose)  by  the 
action  of  the  salivary  ferment,  ptyalin,  and  that  cane  sugar,  as  shown 
by  Leube,  is  changed  into  invert  sugar,  a  mixture  of  cane  and  grape 
sugar.  We  know  that  this  sugar  ferment  exists  not  alone  in  the 
saliva,  but  also  in  small  quantities  in  very  many  tissues,  and  prob- 
ably also  in  the  mucus  which  is  usually  sparingly  secreted  in  the 
stomach.     It  was   formerly  supposed  that   ptyalin   acted   on   the 

*  [Boas.    Loc.  cit,  part  i,  p.  187. — Ed.1 

t  [Friedenwald.    Medical  News,  June  33,  1895.— Ed.] 


70  DISEASES  OF  THE  STOMACH. 

amylaceous  substances  only  in  tlie  mouth  during  mastication.  At 
all  events,  tlie  transformation  of  starch  into  sugar  by  ptyalin  occurs 
very  rapidly  indeed  ;  yet  this  would  not  suffice  to  allow  the  ferment 
to  act  tliorouglily  on  the  more  or  less  compact  masses  swallowed. 
The  saliva  which  is  swallowed  continues  its  action  on  the  amylace- 
ous substances  even  in  the  stomach,  as  has  been  shown  by  von  den 
Yelden.*  The  only  question  is,  How  long  does  this  process  con- 
tinue ?  "We  know  that  pytaHn  acts  best  in  neutral  or  feebly  alkaline 
solutions,  but  is  checked  in  acid  fluids.  It  has  been  shown  that  the 
formation  of  sugar  ceases  as  soon  as  the  amount  of  acid  (reckoned 
for  hydrochloric  acid — a  point  of  vital  importance  to  us)  reaches 
0-01  per  cent  or  more ;  but  in  smaller  quantities  the  action  of  the 
fennent  is  even  somewhat  accelerated  (Chittenden).  With  lactic 
acid  the  acidity  must  be  much  higher,  namely,  O'l  to  0-2  per  cent, 
and  with  butyric  acid  or  fatty  acids  may  be  even  higher  than  this, 
up  to  04  per  cent.f  But,  as  first  shown  in  pigs  and  horses  by 
Ellenberger  and  Hofmeister,;}:  and  in  human  beings  by  Ewald  and 
Boas,  the  simple  taking  of  raw  starch  will  cause  the  secretion  of 
hydrochloric  acid,  to  which  is  later  added  the  lactic  acid  produced 
by  fermentation.  This  naturally  occurs  also  in  a  mixed  diet  with 
amylaceous  substances.  As  normally  the  acidity  of  the  stomach 
contents  gradually  becomes  more  marked  as  more  hydrochloric  acid 
is  secreted,  we  will  hence  observe  an  initial  stage  in  which  starch  is 
still  converted  iato  sugar ;  but  gradually  the  process  becomes  feebler, 
and  finally  ceases  entirely.  Thus  the  conversion  of  starch  into 
sugar  is  not  a  simple  uniform  process,  but,  like  the  digestion  of 
albumen,  there  are  intermediate  products,  the  dextrins  and  maltose.* 
The  two   important  varieties   of  dextrin  are   erythrodextrin   and 


*  R.  V.  d.  Velden.  Ueber  die  Wirksamkeit  des  Mundspeichels  im  Magen. 
Deutsch.  Arch,  fur  klin.  Med.     Bd.  xxv,  S.  105. 

f  According  to  0.  John,  Ueber  die  Einwirkung  fetter  Sauren  auf  die  Starkeum- 
wandlung  durch  den  Speichel.  Inaug.  Dissert.,  Berlin,  1890.  The  action  of  ptyalin 
is  completely  checked  when  lactic  acid  is  O'o  per  cent  and  butyric  acid  1-2  per  cent 
of  the  total  mixture. 

l  Ellenberger  und  Hofmeister.  Arch,  f iir  wissensch.  und  prakt.  Thierheilkunde, 
viii,  S.  395,  and  xii,  S.  126.     Pfliiger's  Archiv,  Bd.  xliv,  S.  484. 

*  See  Ewald.  Klinik,  etc.,  I.  Theil,  3te  Auflage,  S.  55  et  seq.  Also  a  detailed 
account  in  Ewald.  Ueber  die  Zuckerbildung  im  Magen  und  Dyspepsia  acida.  Berl. 
klin.  Wochenschr.,  1886,  No.  48. 


DIGESTION   OP  STARCH  AND  SUGAR.  71 

achroodextrin.  Maltose  is  to  a  certain  extent  an  intemiediate  body 
between  starcli  and  dextrin  on  tbe  one  hand,  and  grape  sugar  on 
the  other. 

Starch  is  recognized  by  the  famihar  deep-bhie  color  struck  with 
iodine  or  a  mixture  of  iodine  and  potassium  iodide — i.  e.,  Lugol's 
solution : 

lodi 0-1  [gr.  jss.] 

Potass,  iodidi 0-2  [gr.  iij] 

Aq.  destillat 200-0  [f  3  vj  3  vj] 

This  reaction  becomes  less  marked  in  proportion  to  the  amount  of 
starch  converted  into  dextrin  and  sugar.  A  solution  of  erythrodex- 
trin,  as  its  name  indicates,  no  longer  gives  a  blue  color,  but  purple ; 
solutions  of  achroodextrin,  maltose,  or  dextrose  assume  no  other 
color  than  the  yellow  of  the  iodine  solution.  The  latter  substances 
have  a  closer  relation  to  iodine  than  dextrin,  and  the  latter  again 
more  than  starch ;  hence,  in  a  mixture  of  these  bodies,  the  first 
drops  of  iodine  solution  added  cause  either  no  color  at  all  or 
only  a  transitory  one,  and  it  is  only  after  adding  more  iodine  that 
the  purple  of  erythrodextrin  or  the  blue  tinge  of  starch  is  ob- 
served. 

As  was  shown  by  von  Mering  in  laboratory  experiments,  and 
by  myself  on  human  beings,  in  the  transformation  of  starch  into 
sugar  by  ptyalin,  the  smaller  portion  only  is  converted  into  dex- 
trose, the  greater  into  maltose.  The  latter  passes  on  into  the  intes- 
tines, where  it  is  changed  into  dextrose  (Brown  and  Heron), 

The  practical  result  of  these  conditions  is  the  following :  If  the 
amylaceous  transformation  proceeds  normally  in  the  mouth  and 
stomach,  after  a  time,  within  r.n  hour  at  least,  so  much  starch  has 
been  changed  into  achroodextrin,  maltose,  or  dextrose  that  the  addi- 
tion of  small  quantities  of  Lugol's  solution  to  the  filtered  stomach 
contents  no  longer  produces  any  changes  of  color.  The  occurrence 
of  a  purple  (erythrodextrin)  or  a  blue  color  (starch)  shows  that  the 
sugar  transformation  has  been  incomplete.  This  may  be  due  either 
to  a  deficiency  of  ptyalin  or  to  a  too  rapidly  increasing  acidity  or 
an  original  hyperacidity  of  the  stomach. 

If,  then,  we  should  be  unable  to  titrate  the  gastric  contents — 
supposing,  for  example,  that  we  had  only  a  very  small  quantity — 


72  DISEASES  OF   THE  STOMACH. 

sucli  a  result  would  of  itself  indicate  a  hyperacidity  of  the  gastric 
juice.  It  seems  that  a  deficiency  in  the  saccharification  power  of 
the  saliva  never  occurs.  For  a  long  time  I  have  tested  thfe  fermen- 
tative power  of  saliva  in  patients  with  dental  caries,  inflammatory 
lesions  in  the  mouth,  angina,  diphtheria,  carcinoma  of  the  tongue, 
and  similar  conditions,  but  never  have  I  found  a  saliva  which  could 
not  convert  starch  into  sugar ;  yet  I  must  not  fail  to  add  that  no 
quantitative  examinations  were  made.  At  my  request  Schlesinger* 
has  made  investigations  to  fill  this  gap ;  he  made  quantitative 
analyses  of  the  action  of  the  saliva  in  twenty -five  pathological  cases, 
and  compared  his  results  with  those  obtained  in  healthy  persons. 
He  found  that  the  maximum  action  in  health  and  in  disease  was 
about  the  same ;  but  the  minimum  action  was  higher  in  healthy  in- 
dividuals by  about  50  per  cent.  At  all  events,  it  seems  that  the 
saliva  does  not  lose  its  ferment,  although  pepsin  may  occasionally 
be  completely  absent  from  the  gastric  juice,  as  occurs  in  the  cases 
of  atrophy  of  the  gastric  mucosa. 

[Kellogg  has  carefully  studied  the  digestion  of  starch  in  the  stom- 
ach by  the  determination  of  the  relative  amounts  of  maltose,  dextrin, 
and  soluble  starch  found  in  the  stomach  contents.  He  has  found 
that  the  average  amount  of  conversion  of  starch  into  maltose  is  80 
per  cent,  the  balance  of  20  per  cent  including  dextrin  and  soluble 
starch.  Much  higher  percentages  of  maltose  are  found  in  hypo- 
chlorhydria  than  in  hyperchlorhydria.  His  results  also  agree  with 
those  of  Ewald,  already  stated,  that  the  activity  of  the  saliva  does 
not  differ  in  hyperchlorhydria  and  hypochlorhydria,  and  hence  the 
differences  in  the  amount  of  starch  conversion  are  due  to  differences 
in  the  gastric  juice.  In  anachlorhydria  starch  digestion  is  usually 
complete. 

The  relations  of  starch  digestion  are  of  interest  in  cases  of  so- 
called  "  buccal  or  salivary  dyspepsia."  The  name  is  poorly  chosen, 
but  it  emphasizes  the  necessity  of  attending  to  the  proper  mastica- 
tion of  food  in  many  cases  of  dyspepsia. f] 

*  A.  Schlesinger.  Zur  Kenntniss  der  diastatischen  Wirkung  des  menschlichen 
Speichels.     Virchow's  Archiv,  Bd.  cxxv  und  cxxvi,  p.  354. 

f  [Further  details  may  be  found  in  Kellogg's  papers  in  Modern  Medicine,  Feb- 
ruary, March  and  April,  1896. — Ed.] 


RELATIONS  07  SALIVA  AND  GASTRIC  JUICE,  73 

According  to  Wriglit  *  and  Sticker,  f  the  cessation  of  the  action 
of  the  saliva  upon  the  stomach  is  followed  by  a  diminution  or  stop- 
page of  the  secretion  of  gastric  juice ;  consequently  the  digestion  both 
of  starch  and  also  of  albumen  suffers  on  this  account.  Biernacki  :j: 
has  attributed  this  to  the  carbonic  acid  and  carbonates  which  are 
present  in  the  saliva  and  which  have  a  slight  stimulating  action  on 
the  gastric  mucosa.  It  has  long  been  known  that  reflex  relations 
exist  between  mastication  and  the  gastric  functions ;  nevertheless 
numerous  cases  of  gastrotomy  after  total  cicatricial  closure  of  the 
oesophagus  (as,  for  example,  the  well-known  case  of  Eichet*)  prove 
that  the  secretion  of  gastric  juice  may  occur  independently  of  any 
action  of  the  saliva. 

Sugar  may  always  be  found  in  the  stomach  contents  after  the 
various  test  meals,  since  a  certain  amount  is  contained  in  them. 

Finally,  I  must  state  that  bile  may  be  detected  in  the  contents  of 
the  stomach  by  the  greenish  tinge  it  imparts,  or  by  Gmehn's  test- 
It  is  also  characteristic  of  biliary  pigment  that  the  bright  yellow 
debris  left  upon  the  filter  upon  filtering  the  stomach  contents  after 
the  test  breakfast,  and  especially  that  portion  at  the  edge  of  the 
filter,  assumes  a  greenish  tinge  by  oxidation  after  prolonged  expo- 
sure to  the  air.  It  is  to  be  noted  that  stomach  contents  containing  a 
large  amount  of  HCl  which  have  been  taken  from  the  stomach  while 
fasting  often  have  a  greenish  color,  yet  no  biliary  pigments  can  be 
demonstrated  with  the  ordinary  reagents.  [Trypsin,  urea,  blood, 
pus,  and  mucin  are  also  found  in  the  stomach  contents.] 

[All  of  the  various  procedures  ought  to  be  done  with  the 
stomach  contents  which  are  obtained  after  test  meals.  To  depend 
exclusively  upon  vomited  matters  is  often  very  misleading,  and  they 
should  only  be  employed  when  for  various  reasons  test  meals  can 
not  be  given. 

At  times  important  data  can  be  obtained  by  the  passage  of  the 
stomach  tube  while  fasting.     What  the  stomach  contains  at  this 

ii  Wright.     The  Physiology  and  Pathology  of  the  Saliva.     London,  1841. 
f  G.  Sticker.     Wechselbeziehungen  zwischen  Speichel  und  Magensaft.    Volk- 
mann's  Vortrage,  No.  297. 

X  Biernacki.     Reviewed  in  Virchow-Hirsch  Jahresber.,  1891. 
*  Ewald.     Klinik,  etc.,  L  Theil,  3te  Auflage,  p.  114. 


74 


DISEASES  OP  THE  STOMACH. 


time  has  already  been  discussed  (page  IS).  Indeed,  tlie  diagnosis 
of  continuous  hypersecretion  and  the  prognosis  of  many  cases  of 
lessened  motility  of  the  stomach  are  directly  based  upon  what  is 
obtained  by  the  passage  of  the  tube  while  fasting.  The  presence  of 
large  quantities  (over  60  c.  c. —  §  ij)  would  seem  to  be  pathological. 
Occasionally  intestinal  contents  may  be  found  in  the  stomach  while 
fasting ;  under  these  conditions  the  stomach  contents  may  even  be 
alkaline  in  reaction.] 

[Microscopic  Examination  of  the  Stomach  Contents. — This  ought 
not  to  be  omitted,  although  the  results  are  very  varying  and  often 
of  no  great  diagnostic  value  ;  yet  we  may  derive  benefit  from  it 
when  least  expected.     We  observe  food  fragments,  starch  granules, 


[Fig.  6. — Microscopic  appearance  of  stagnating  stomach  contents.  1  and  2,  sarcinffi  ventri- 
culi ;  3,  yeast  cells ;  4,  fatty  acid  needle  crystals  ;  5,  fat  droplets  ;  6,  starch  granules  ;  7, 
partly  digested  meat  fiber,    from  Eiegel.] 

plant  cells,  fat  cells,  muscular  fibers,  elastic  fibers,  and  connective 
tissues ;  various  forms  of  flat  epithelial  cells  of  the  mouth  and 
oesophagus ;  less  frequently  Cylindrical  cells  from  the  stomach  and 
leucocytes  (Fig.  6).  A  few  red  blood-cells  are  not  pathological. 
Pus  cells  may  also  be  observed.  Parasites  are  frequently  found ; 
these  include  yeast  cells,  mold  fungi,  sarcinse,  bacteriae,  and  micro- 
cocci.    Among  the  bacteriae  the  most  important  are  the  lactic  acid 


TESTS   FOR  OASTRIC   ABSORPTION.  75 

bacilli  and  Oppler's  long  bacilli,  the  latter  of  wbicli  seem  to  occur 
very  frequently  in  cancer  of  the  stomach. 

The  exact  details  of  the  microscopical  appearances  in  the  various 
disorders  of  the  stomach  will  be  found  in  the  chapters  on  these 
diseases. 

At  times  bacteriological  examinations  of  the  stomach  contents 
may  be  of  service.*  Under  normal  conditions,  after  giving  sterilized 
food  no  bacteria  will  be  obtained.] 

There  are  still  two  factors  to  be  discussed — the  absorptive  power 
of  the  stomach  and  its  motor  functions — two  points  which  have 
recently  been  underestimated  because  they  have  been  overshadowed 
by  purely  chemical  examinations. 

Absorption  by  the  gastric  mucous  membrane  is  tested  with  potas- 
sium iodide.  Penzoldt  f  recommends  giving  it  [on  an  empty  stom- 
ach] in  small  doses  of  0*1  gramme  [gr.  jss.]  in  capsules  which  have 
been  carefully  wiped  off,  so  that  none  of  the  drilg  adheres  to  the 
outside  of  the  capsule.  A  capsule  is  taken,  and  the  moment  iodine 
appears  in  the  saliva  is  determined  by  means  of  the  well-known 
reaction  with  starch  paste.  Filter  paper  is  moistened  with  starch 
paste  and  dried  ;  after  the  capsule  is  taken,  from  time  to  time,  say 
every  five  minutes,  a  little  of  the  patient's  saliva  is  placed  upon  the 
dried  filter  paper  ;  then,  by  adding  some  fuming  nitric  acid  (one  or 
two  drops),  the  appearance  of  a  blue  color  will  indicate  exactly  when 
the  iodine  appears  in  the  saliva.  E^ormally  this  occurs  in  ten  to 
fifteen  minutes ;  but  in  processes  where  absorption  by  the  stomach 
is  slow  or  fails  entirely,  this  reaction  occurs  much  later,  being  de- 
layed a  half  to  a  whole  hour,  or  even  longer. 

These  statements  were  first  tested  and  in  general  confirmed  by 
Boas,  and  later  on  by  Zweifel  X  and  Haeberlein.*    However,  Boas  || 

*  [Turck.  N.  Y.  Medical  Journal,  November  23,  1895 ;  ibid.,  February  22,  1896 ; 
Medical  News,  April  4,  1890.  Kaufmann.  Berl.  klin.  Woehenschr.,  1895,  No.  6. 
—Ed.] 

f  Penzoldt  und  Faber.  Resorptionfahigkeit  des  menschlichen  Magens.  Berl. 
klin.  Woehenschr.,  1882,  No.  21. 

X  Zweifel.  Ueber  die  Resorptionsfahigkeit  des  menschlichen  Magens,  etc.  Deutsch. 
Arch,  fiir  klin.  Med.,  Bd.  xxxix,  p.  349. 

*  Haeberlein.  Ueber  neue  diagnostische  Hiilfsmittel  bei  Magenkrebs.  Deutsch. 
Arch,  fiir  klin.  Med.,  Bd.  xlv,  p.  347. 

II  Boas.     Loc.  cit.,  p.  179. 


76  DISEASES  OP  THE  STOMACH. 

correctly  objects  that  this  test  has  no  specific,  differential  diag- 
nostic value,  as,  for  instance,  between  ulcer,  cancer,  and  dilatation 
of  the  stomach.  The  same  is  true  of  Sahli's  potassium  iodide  fibrin 
capsules,  described  on  page  lY.  At  all  events,  when  the  absorption 
is  delayed  for  60  to  90  minutes  some  pathological  condition  must 
exist.  The  method  therefore  enables  us  to  determine  gross  changes 
in  the  absorptive  powers  of  the  gastric  mucosa. 

[Very  little  practical  importance  can  be  placed  upon  the  results 
of  the  potassium  iodide  test,  since  it  has  been  shown  that  the  results 
vary  when  the  capsules  are  taken  on  an  empty  stomach  or  even  dur- 
ing various  stages  of  digestion.  The  brilliant  experiments  of  Yon 
Mering  *  have  shown  that  gastric  absorption  is  a  very  complex 
process,  for  all  substances  are  not  equally  rapidly  absorbed  in 
the  stomach ;  on  the  contrary,  some  substances  cause  the  fluids  to 
move  in  the  opposite  direction — i.  e.,  excretion.  Thus  he  has  found 
by  experiments  on  animals  with  duodenal  fistulse  that  as  much  or 
even  more  water  flows  out  of  the  fistula  as  was  given  by  the  mouth 
and  therefore  concludes  that  water  is  not  absorbed  by  the  stomach. 
These  experiments  were  confirmed  by  Moritz.f  Yon  Mering  also 
found  that  alcohol,  peptones,  sugar,  dextrin,  sodium  chloride,  and 
carbonic  acid  are  absorbed.  The  amount  absorbed  increases  with 
the  concentration  of  the  solution,  but  along  with  the  absorption  of 
these  substances  there  is  a  more  or  less  active  excretion  of  water 
into  the  stomach,  the  amount  of  which  increases  with  the  quantity 
of  these  substances  absorbed.  The  excretion  of  water  into  the 
stomach  occurs  when  the  presence  of  HCl  in  the  stomach  can  not  be 
demonstrated.  Thus,  unlike  what  occurs  in  the  intestines,  absorp- 
tion in  the  stomach  seems  to  be  a  process  of  diffusion. 

These  results  are  of  the  utmost  importance  in  the  treatment  of 
dilatation  of  the  stomach. 

This  subject  has  also  been  recently  studied  by  Meltzer,;}:  who 
shows  how  little  understood  these  processes  are.     His  experiments 


*  [Von  Mering.     Therapeutische  Monatshefte,  1893,  p.  201.— Ed.] 
t  [Moritz.     Milneh.   med.   Wochenschr.,    1893,   No.   38  ;    ibid.,   1894,   No.   41. 
— Ed.J 

$  [Meltzer's  paper,  which  was  read  before  the  May  (1896)  meeting  of  the  Asso- 
ciation of  American  Physicians,  has  not  yet  been  published. — Ed.] 


TESTS   FOR   GASTRIC   MOTOR  FUNCTIONS.  77 

demonstrate  that  the  absorptive  powers  of  the  stomach  have  l^een 
greatly  overestimated.] 

Another  question  is,  How  can  we  test  the  motility  or  motor  func- 
tion of  the  stomach  ?  The  determination  of  the  normal  peristalsis 
and  proper  movement  of  the  ingesta  in  and  expulsion  out  of  the 
stomach  is  very  important,  because  the  timely  evacuation  of  the 
chyme  into  the  intestines  will  compensate  for  a  deficiency  in 
the  gastric  digestion,  while,  on  the  other  hand,  any  lessening  of  the 
motility  gives  rise  to  a  series  of  well-marked  disturbances,  the 
nature  of  which  we  will  discuss  later  under  motor  insufiiciency  of 
the  stomach. 

To  show  how  completely  the  absolute  absence  of  any  true  gastric 
digestion  may  be  compensated  by  means  of  good  motor  functions,  I 
shall  cite  the  following  examples  : 

I  had  under  my  observation  for  four  years  a  gentleman,  whom  I  have 
since  lost  track  of,  whose  stomach  contents  I  examined  several  times 
yearly,  and  yet  was  never  able  to  detect  free  hydrochloric  acid  and  pep- 
sin. He  went  to  Kissingen  every  summer,  felt  tolerably  well,  ate  large 
dinners,  and  pursued  his  occupation  ;  and  yet  I  must  confess  that  without 
exception  hydrochloric  acid  and  pepsin  have  been  absent  in  every  test 
made  at  various  intervals  after  eating  different  kinds  of  food,  both  the 
test  breakfast  as  well  as  larger  meals.  Dr.  L.  "Wolff  and  myself  *  have 
published  analogous  cases.  I  have  also  had  a  similar  experience  in  a 
female  patient  upon  whom  gastrotomy  was  performed  for  carcinoma  of 
the  oesophagus.  I  have  published  another  case  which  I  had  watched  for 
three  years,  and  had  repeatedly  examined  at  different  times  after  giving 
various  kinds  of  food.  At  all  times,  physiologically  active  (free  and 
loosely  combined)  HCl,  pepsin,  and  rennet  were  absent.  In  spite  of  this 
he  felt  very  well  under  the  systematic  use  of  HCl  and  gained  46  pounds. 

From  this  we  may  infer  that  under  certain  circumstances  the 
secretory  function  of  the  stomach  is  not  essential  to  maintain  life, 
providing  that  the  lesion  in  the  stomach  does  not  of  itself  imperil 
life  by  a  general  intoxication,  but  that  under  these  conditions  the 
intestinal  digestion  seems  to  vicariously  assume  the  entire  burden. 
This  is  plausible,  since  the  chemical  processes  of  digestion  are 
doubly  provided  for :  two  secretions  digest  starch — i.  e.,  saliva  and 
the  pancreatic  juice ;  albumen  may  be  peptonized  at  two  places,  the 

*  L.  Wolff  und  Ewald.  Ueber  das  Fehlen  der  freien  Salzsaure  im  Mageninhalt. 
Berl.  kiln.  Wochenschr.,  1887,  No.  80;  and  Ewald,  ibid.,  1887,  No.  49, Verhand- 
lungen  des  Vereins  fiir  itmere  Medicin  ;  ibid.,  1892,  No.  26. 


78  DISEASES  OF  THE  STOMACH. 

stomacli  and  intestines ;  and  fats  may  be  emulsified  by  the  pancreatic 
jnice  and  bile.  The  intestmes  are  thus  capable  of  acting  vicariously 
for  the  stomach,  if  necessary.  Similar  conclusions  have  been  reached 
by  other  writers.  But  Jaworski  has  gone  to  extremes  in  maintain- 
ing that  the  chemical  functions  of  the  stomach  play  a  subordinate 
j)art,  and  that  the  stomach  is  nothing  more  than  a  storeroom  and 
warming  place  where  the  food  may  enter  and  be  admitted  to  the 
intestine  as  through  a  sluice.  Bunge  *  has  also  gone  too  far  in 
asserting  that  the  HCl  acts  only  as  an  antiseptic,  and  has  no  peptic 
powers  in  digestion.  This  is  a  wild  speculation,  which  brings  us 
back  to  the  old  HipiDocratic  doctrine  of  the  cdctio  ciborum,  the 
cooking  of  the  food  by  the  animal  heat. 

The  most  positive  means  of  determining  how  soon  the  stomach 
evacuates  its  contents — i.  e.,  the  estimation  of  the  propulsive  powers 
of  the  stomach — are  still  the  methods  by  which  we  determine  the 
duration  of  digestion.  The  best  is  Leitbe's  method,  in  which 
we  give  his  test  dinner  and  pass  the  tube  6  or  7  hours  later,  when 
normally  the  stomach  ought  to  be  empty  ;  or,  according  to  Ewald, 
the  stomach  ought  to  be  found  empty  If  to  2  hours  after  the  test 
breakfast.  However,  ignoring  the  fact  that  the  introduction  of  the 
tube  is  necessary,  the  method  is  nevertheless  not  absolutely  reliable, 
because  the  physiological  evacuation  of  the  stomach  is  subject  to 
many  variations,  and  therefore,  at  best,  we  can  only  use  the  longest 
periods  as  standards.  Furthermore,  we  can  never  be  absolutely  cer- 
tain that  the  stomach  is  empty  unless  after  repeated  washings, 
since,  as  is  well  known,  large  residues  of  food  may  not  infrequently 
be  raised  just  at  the  conclusion  of  prolonged  lavage.  Fiaally,  ab- 
sorption as  well  as  motility  is  involved  in  this  test. 

Salol  Test. — For  the  separate  determination  of  the  latter  I  have 
proposed  the  use  of  salol. f  Salol  is  a  compound  of  phenol  and 
salicylic  acid — a  phenol  etlier  of  salicylic  acid  which,  according  to 
l^encki,  is  not  changed  by  acids  but  is  converted  by  the  action  of 

*  [Lehrbueh  der  physiol.  und  patholog.  Chemie,  2te  Auflage,  pp.  143  et  seq.  Al- 
though some  of  the  statements  made  in  this  chapter  are  very  radical,  they  will  well 
repay  perusal  for  the  comparative  chemistry  of  the  gastric  juices  in  the  different 
species. — Ed.] 

t  Sievers  und  Ewald.  Zur  Pathologie  und  Therapie  der  Magenectasien.  Ther- 
apeutische  Monatshefte,  August,  1887. 


SALOL   TEST.  79 

the  pancreas  and  the  intestinal  bacteria  into  salicylic  acid  and  phenol. 
Dr.  Sievers,  of  Helsingfors,  and  mjself  undertook  a  series  of  obser- 
vations which  showed  that  salol  is  decomposed  by  relatively  feeble 
alkaline  fluids — for  example,  the  saliva — but  that  it  is  not  decomposed 
when  introduced  into  the  stomach,  or  when  mixed  outside  of  this 
viscus  with  acid  stomach  contents  or  artificial  digestive  mixtures 
with  pepsin  and  hydrochloric  acid.  This  fundamental  principle  I 
have  again  demonstrated  recently  upon  a  patient  with  a  gastric  fis- 
tula, who  had  a  mild  degree  of  hyperchlorhydria,  and  into  whose 
stomach  at  the  height  of  digestion  salol  was  introduced  through  the 
fistula.  Consequently,  the  statements  made  to  the  contrary  by  Reale 
and  Grande  *  may  be  attributed  to  faulty  methods.  On  the  other 
hand,  the  question  arises  whether  salol  may  not  be  directly  absorbed 
by  the  gastric  mucous  membrane  and  subsequently  split  up  in 
the  tissues.  According  to  experiments  made  by  Stein,f  in  which 
salol  was  introduced  into  the  stomach  after  double  ligation  of  the 
pylorus  from  the  duodenum,  this  may  occur  when  the  salol  is  re- 
tained in  the  stomach  for  many  hours.  My  experiments,  which  were 
not  repeated  by  Stein,  and  in  w^hich  the  relations  of  the  salol  were 
studied  only  for  the  first  two  hours,  showed  the  contrary.  Conse- 
quently, the  splitting  up  of  salol  into  salicylic  acid  and  phenol,  and 
the  appearance  in  the  urine  of  salicyluric  acid,  the  product  of  the 
decomposition  of  salicylic  acid,  will  indicate  that  the  salol  has  actu- 
ally passed  out  of  the  stomach. 

Salol  is  a  white,  tasteless  powder,  which  is  best  given  in  capsules 
to  prevent  any  action  of  the  saliva  ;  one  gramme  [15  grains]  is  given 
in  three  capsules,  preferably  at  the  height  of  digestion.  Salicyluric 
acid  is  easily  recognized  in  the  urine  by  the  violet  color  produced 
on  the  addition  of  neutral  ferric-chloride  solution.  A  simple  method 
is  to  place  several  drops  of  urine  on  a  piece  of  filter  paper  and  then 
let  a  drop  of  a  10-per-cent  ferric-chloride  solution  fall  upon  the 
moistened  spot  on  the  filter  paper.  The  edge  of  the  drop  will 
assume  a  violet  color  in  the  presence  of  even  the  smallest  trace  of 
salicyluric  acid. 

*  Reale  and  Grande.  Sulla  scomposizione  del  salolo  nello  stomaeo.  Rivista 
clin.,  October,  1891. 

f  Stein.  Ueber  die  Verwendbarkeit  des  Salol  zur  Prufung  des  Magens, 
Wiener  med.  Wochenschr.,  1893,  No.  43. 


80  DISEASES  OF  THE  STOMACH. 

In  tlie  great  majority  of  cases  this  reaction  occurs  60  to  75  min- 
utes after  taking  the  salol.  Unfortunately,  in  this  method  the  time 
of  the  decomposition  of  the  salol  depends  on  the  occurrence  of  the 
neutral  or  alkaline  reaction  of  the  intestine  ;  even  under  normal 
conditions  this  may  vary,  since  it  depends  on  the  changeable  reaction 
of  the  chyme  and  the  quantity  of  bile  and  pancreatic  juice  which 
reaches  the  intestines.  Hence  the  time  of  the  reaction  is  subject  to 
variations  wliich  some  observers  consider  to  be  so  great  as  to  render 
the  method  useless. 

Huber  *  has  therefore  proceeded  in  the  reverse  direction,  and 
has  estimated  the  time  which  elapses  from  the  taking  of  the  salol  to 
the  complete  disappearance  of  the  reaction  in  the  urine.  In  healthy 
persons  this  excretion  lasts  24  hours ;  in  patients  with  enfeeblement 
of  the  motor  functions  of  the  stomach  it  lasted  48  hours,  or  even 
longer.  Silberstein  f  experimented  with  this  method  on  26  cases 
of  gastric  dilatation  and  12  cases  of  atony  of  the  muscular  fibers  of 
the  stomach ;  the  excretion  of  salicyluric  acid  lasted  till  the  second 
day — i.  e.,  30  hours  or  more.  The  condition  of  the  bowels,  diar- 
rhoea or  constipation,  apjDcared  to  exert  no  influence.  [To  carry 
out  Huber's  test,  one  gramme  [gr.  xv]  of  salol  is  given,  and 
the  urine  is  examined  24  to  30  hours  later.  If  salicyluric  acid 
is  still  present  at  the  latter  period,  or  even  later,  we  may  with  tol- 
erable certainty  infer  a  disturbance  of  the  muscular  activity  of  the 
stomach.] 

It  is  self-evident  that  the  objections  which  may  be  raised  against 
the  original  method  also  apply  to  Huber's  modification.  In  my 
opinion,  demands  have  been  made  upon  the  method  which  are  im- 
possible, and  which  Sievers  and  myself  never  claimed  for  it,  since  it 
will  only  indicate  gross  changes  in  the  emptying  of  the  stomach.  In 
the  experiments  of  Wotitzky,:}:  the  average  reaction  time  in  gastric 
disorders  was  132  minutes  ;  in  various  other  diseases  69  to  90  min- 
utes.    For  this  purpose  it  is  amply  sufficient,  and  on  account  of  its 


*  A.  Huber.  Zur  Bestimmimg  der  raotorischen  Thatigkeit  des  Magens.  Miineh. 
med.  Wochenschr.,  1887,  No.  19. 

t  Silberstein.     Deutsch.  med.  Wochenschrift,  1891,  No.  9. 

X  Wotitzky.  Ueber  der  diagnostischen  Werth  des  Salols.  Prager  med.  Woch- 
enschr., 1891.  No.  31. 


OIL  TEST,  81 

simplicity  is  preferable  to  Leube's  method  and  Klemperer's  oil 
test* 

Oil  Test. — Klemperer  f  has  proposed  another  method  for  deter- 
mining the  motor  activity  of  the  stomach.  He  pours  a  definite 
quantity — 100  c.  c.  [f  §  iij  3  ij] — of  pure  olive  oil  into  the  empty 
stomach,  which  has  previously  been  washed  out,  if  necessary ;  two 
hours  later  the  stomach  is  aspirated,  and  whatever  oil  is  left  is  re- 
moved as  thoroughly  as  possible  till  only  an  insignificant  trace  re- 
mains. The  difference  between  the  original  quantity  of  oil  and 
that  aspirated  is  used  by  him  as  an  indication  of  the  motor  function 
of  the  stomach.  However,  even  Klemperer  himself  admits  that  this 
method  can  not  be  always  used  in  general  practice,  because  it  is 
complicated  and  objectionable  to  patients.  Under  certain  condi- 
tions this  test  may  even  do  harm,  since  it  can  not  be  a  matter  of  in- 
difference to  inflict  so  large  a  quantity  of  fat  upon  a  diseased  stom- 
ach or  intestine.  [Recently  Matthieu  :|:  has  proposed  a  modified  oil 
test.  Ten  grammes  of  an  oil  emulsion  are  given  with  a  test  break- 
fast, the  amount  of  oil  obtained  after  a  definite  interval  being  deter- 
mined by  extracts  with  ether  and  weighing.  The  process  is  too 
complicated  for  clinical  use.] 

[It  is  no  exaggeration  to  say  that  the  examination  of  the  motor 
functions  of  the  stomach  is  equally  as  important  as  the  testing  for 
HCl.  In  the  zealous  pursuit  of  tests  for  the  latter  the  motility  was 
much  neglected  up  to  a  short  time  ago,  when  it  was  recognized  how 
essential  it  was  to  know  exactly  the  peristaltic  powers  of  the  stom- 
ach. The  motility  may  be  lessened,  as  occurs  in  atony  and  dilata- 
tion of  the  stomach  ;  or  it  may  be  increased,  as  shown  in  peristaltic 
unrest  and  in  hyperkinesis  (see  Chapter  XI).  In  the  former  the 
emptying  of  the  stomach  is  delayed  for  varying  intervals ;  in  the 
latter  the  food  leaves  the  stomach  unduly  early,  the  stomach  being 
often  found  empty  three  hours  after  Leube's  test  dinner. 

The  general  concensus  of  opinion  to-day  is  that  the  salol  tests 


*  [A  death  has  been  reported  from  the  use  of  this  method.  See  London  Lancet, 
May  23,  1891.     Such  an  accident  must  be  regarded  as  a  very  rare  event. — Ed.] 

f  Klemperer.  Ueber  die  motorisehe  Thatigkeit  des  menschlichen  Magens. 
Deutsche  med.  Wochenschr.,  1887,  No.  47. 

X  [Matthieu,     Boas's  Archiv  fiir  Verdauungskranlvheiten,  Bd.  i,  p.  345.— Ed.] 


82  DISEASES  OP  THE  STOMACH. 

are  too  unreliable,  and  tliat  tlie  best  method  is  that  of  Lenbe.  Boas 
has  modified  this  for  determining  various  degrees  of  stagnation  of 
the  stomach  contents  in  atony  and  dilatation.  After  cleaning  the 
storaach  he  gives  his  test  sxipper^  which  consists  of  some  cold  meat, 
vs^heat  bread  and  butter,  and  a  large  cup  of  tea.  Normally,  on  pass- 
ing the  tube  early  the  next  morning  the  stomach  ought  to  be 
empty. 

In  testing  the  motility,  it  is  equally  important  to  ascertain  the 
tone  of  tJie  muscula/r'  fibers.  This  may  be  accomplished  with  Dehio's 
method  for  determining  the  size  of  the  stomach  {mde  supra) ;  the 
successive  areas  of  dullness  reach  down  lower  than  normal  on  succes- 
sively percussing  the  greater  curvature  (in  the  upright  position)  after 
successively  drinking  two  to  three  glasses  of  water  (Riegel).  In 
lavage,  the  force  with  which  the  water  is  expelled  or  the  rapidity 
with  which  the  fluid  enters  the  stomach  is  also  a  good  criterion.* 

To  determine  the  actual  peristaltic  power  of  the  stomach,  Ein- 
horn  has  devised  his  gastrograj)h,\  an  instrument  which  is  not 
adapted  for  clinical  use  and  the  utility  of  which  the  future  can  alone 
determine,  as  the  observations  thus  far  published  by  Einhorn  are 
not  yet  sufficient  to  allow  one  to  draw  any  conclusions. 

The  same  may  be  said  of  Hemmeter's  intragastric  bags  X  for 
obtaining  records  of  the  motor  functions  of  the  stomach  on  the 
ky  m  ographion .  ] 

The  physical  methods  of  examination,  the  second  great  group  of 
our  diagnostic  aids,  I  can  only  speak  of  here  in  so  far  as  they  have 
a  direct  bearing  upon  the  examination  of  the  stomach,  or  are  con- 
nected with  it  in  some  pecuhar  manner.  I  shall  refrain  from  enter- 
ing into  the  elementary  rules  for  determining  the  topography  of  the 
stomach,  since  they  may  be  found  in  every  text-book  on  physical 
diagnosis.  Moreover,  in  the  description  of  the  various  diseases,  I 
shall  have  many  opportunities  to  speak  of  percussion,  auscultation. 


*  [A  good  discussion  of  this  subject  will  be  found  in  Kaufmann,  N.  Y.  Medical 
Journal,  March  28,  1896.— Ed.] 

f  [Einhorn.  N.  Y.  Medical  Journal,  September  15,  1894 ;  Zeitschr.  fiir  klin. 
Med.,  1895,  Bd.  xxvii,  p.  242.] 

%  [Hemmeter.     N.  Y.  Medical  Journal,  June  22,  1895.— Ed.] 


PALPATION   OP   ABDOMEN.  83 

inspection,  etc.,  so  that  I  shall  now  restrict  myself  to  the  following 

points : 

1.  Palpation. — Of  all  the  various  means  of  examining  the  ab- 
dominal organs  this  is  undoubtedly  the  most  unportant.     Whoever 
can  palpate  well,  and  has  a  dehcate  sense  of  touch,  possesses  an  ad- 
vantao-e  in  diagnosis  which  is  not  to  be  overestimated.     ISTaturally 
there  must  always  be  a  combination  of  the  tactile  impression  and 
the  mental  process  which  will  enable  the  observer  at  that  particular 
moment  to  draw  upon  the  whole  range  of  his  experience  and  to  use 
it  upon  the  case  in  question ;  or,  to  use  a  figure  of  speech,  which 
will  enable  him  to  look  through  the  abdomiaal  walls  and  direct  his 
fino-ers.     But  a  proper  technique  is  very  important  here,  and,  as  I 
so  often  see  errors  committed  and  examinations  rendered  difficult 
and  uncertain,  I  shall  be  pardoned  if  I  call  attention  to  several  very 
.  well  known  points  :  I^ever  palpate  with  the  hand  held  perpendicu- 
larly or  obliquely  to  the  abdominal  wall ;  gradually  and  carefully  go 
deeper  by  small  rotatory  movements  in  a  horizontal  plane.     Place 
your  hands  flat  upon  the  abdomen,  and  only  press  down  gradually 
and  very  gently   by  bending   the   end   phalanges.     In  this   way 
we  not  alone  prevent  the  contraction  of  the  abdominal  muscles 
whose   edges  have   caused   errors   and   uncertainty   in   even   very 
experienced   clinicians,   but    we   also   obtain   a  much  better  per- 
ception of  the  site,  size,  and  form  of  any  peculiar  conditions  beneath 
the  abdominal  wall ;  and,  finally,  last  but  not  least,  we  cause  a  mini- 
mum of  discomfort  and  pain  to  the  patient.     Here  the  same  con- 
siderations are  true  as  in  percussion.     As  is  well  know,  differences 
of  tone  which  are  perceptible  with  gentle  percussion  are  overlooked 
when  it  is  forcible.     It  is  hardly  necessary  to  state  that  under  cer- 
tain circumstances  firmer  pressure  may  be  needed  in  palpation,  and 
a  stronger  stroke  may  be  required  in  percussion,  yet  such  cases 
always  have  peculiar  features  which  distinguish  them  from  the  ordi- 
nary ones.     Sometimes  it  may  be  of  great  advantage  to  supplement 
the  palpation  in  the  dorsal  and  lateral  posture  by  examining  the 
patient  in  the  knee-elbow  position.     Movable  tumors  will  then  sink 
against   the   anterior  abdominal  wall,  and  may  be   recognized  as 
such. 

I  also  wish  to  direct  attention  to  two  points  which  may  easily  lead 


84  •  DISEASES  OP  THE   STOMACH. 

to  doubt  and  error,  and  upon  which,  so  far  as  I  know,  sufficient 
stress  has  nowhere  been  laid.  The  first  point  is  concerning  palpa- 
tion of  the  pancreas.  IN^ormallj,  the  pancreas  lies  behind  the  stom- 
ach, being  covered  bj  the  lesser  curvature,  above  which  it  projects 
a  little.  Usually,  and  especially  when  the  stomach  is  filled  with  food, 
it  can  not  be  palpated.  It  is  different,  however,  when  the  abdominal 
parietes  are  emaciated  and  relaxed,  the  stomach  empty,  and  its  walls 
thin.  Then  an  indefinite  tumor  may  be  palpated  in  the  epigastric 
region ;  it  may  be  differentiated  by  a  very  careful  determination  of 
the  borders  of  the  liver,  by  its  absolute  immobihty,  by  its  deep  situa- 
tion, by  its  flat  and  extended  shape,  by  distending  the  stomach,  and 
by  the  absence  of  any  symptoms  which  might  indicate  a  neoplasm. 
Its  recognition  is  much  more  difficult  when  the  stomach  is  dislocated 
downward,  as  occurs  in  gastroptosis  ;  here  the  pancreas  lies  uncov- 
ered to  a  greater  or  less  extent  above  the  lesser  curvature.  After 
distending  the  stomach,  the  suspected  tumor  may  be  demonstrated 
above  the  lesser  curvature  in  the  hollow  formed  by  the  inner  half 
of  the  right  costal  border,  the  ensif  orm  process,  and  the  lesser  curva- 
ture ;  it  may  be  felt  much  more  readily  as  the  latter  sinks  more 
and  more  toward  the  umbilicus,  the  level  of  which  it-  actually 
reaches  in  extreme  cases.  Under  these  circumstances  we  feel  a 
smooth,  transversely  situated,  immovable  band,  which  feels  like  a 
piece  of  contracted  gut  lying  transversely  over  the  vertebral  column, 
and  which  is  tender  on  pressure,  evidently  the  result  of  irritation  of 
the  nervous  plexus.  But  careful  exploration  and  a  knowledge  of 
the  pathological  conditions  will  prevent  any  errors. 

The  second  point  is  the  following,  which  may  at  times  cause 
much  more  confusion.  A  lymphatic  gland  lies  at  about  the  middle 
of  the  greater  curvature,  not  in  the  wall  of  the  stomach,  but  in  the 
gastro-colic  ligament.  In  inflammatory  conditions  within  or  about 
the  stomach  this  gland  enlarges  and  may  become  palpable,  especially 
when  the  stomach,  as  the  result  of  an  axial  rotation,  is  pressed  more 
closely  than  usual  against  the  abdominal  parietes.  It  may  then  at 
times  be  palpated  as  a  small,  movable  tumor,  about  the  size  of  a 
hazelnut  or  walnut,  and  which  can  be  shown  to  belong  to  the  stom- 
ach by  inflation  of  the  latter  (or  at  times  the  colon).  It  disappears 
or  becomes  less  distinct  when  the  stomach  sinks  backward,  when 


DISTENTION   OF  STOMACH  WITH  GAS.  85 

the  patient  lies  on  his  back,  or  when  tlie  intestines  rise  in  front  of 
the  stomach.  Furthermore,  it  may  become  smaller  when  the  ori- 
ginal inflammatory  process  abates  and  can  then  no  longer  be  pal- 
pated. I  must  confess  that,  until  I  had  convinced  myself  of  these 
conditions  at  autopsies,  I  have  been  very  much  worried  by  certain 
obscure  cases  and  have  occasionally  made  an  incorrect  diagnosis  of 
carcinoma.  Hence  the  importance  of  laying  stress  upon  this 
point. 

On  the  other  hand,  I  need  scarcely  caution  against  the  error 
which  is  not  infrequently  committed  by  novices,  of  mistaking  for  a 
tumor  the  pulsating  aorta  which  often  seems  to  lie  just  under  the 
abdominal  parietes,  when  the  latter  are  much  sunken  in  and  the 
vertebral  column  somewhat  arched  forward;  in  such  cases  it  has 
been  supposed  that  the  pulsations  are  due  to  transmission  to  the  sus- 
pected tumor  from  the  underlying  aorta,  whereas  it  was  only  the  ves- 
sel itself  which  was  felt.     [See  also  beginning  of  Chapter  YI.] 

2.  Distention  of  the  Stomach  with  Carbonic- Acid  Gas  or  Air. — The 
method  of  distending  the  stomach  with  carbonic-acid  gas  generated 
in  loco  was  introduced  by  Yon  Frerichs,  and  since  then  has  been  in 
general  use.  Yon  Ziemssen,*  following  the  American  method, 
applied  it  also  to  the  intestines  by  administering  per  rectum  bicar- 
bonate of  soda  and  some  organic  acid  ;  we  may  also  employ  carbonic- 
acid  gas  already  generated  outside  of  the  body — for  example,  from 
an  inverted  siphon  of  mineral  water  (Schnetter  and  Rosenbach).f 
These  methods  suffer  from  the  disadvantages  that  we  have  no  con- 
trol over  the  amount  of  gas  produced  after  the  salts  have  been  intro- 
duced into  the  stomach  or  intestines,  that  disagreeable  accompany- 
ing symptoms  frequently  arise  from  the  irritation  of  the  carbonic- 
acid  gas  upon  the  walls  of  the  stomach  or  intestines,  and  that,  even 
though  varying  quantities  of  gas  are  needed  for  different  persons, 
the  degree  of  tension  produced  can  not  be  regulated  at  will  nor  in- 
creased at  a  given  mpment.     [A  teaspoonful  of  sodium  bicarbonate 


*  Von  Ziemssen.  Die  kiinstliche  Gasaufblahung  des  Dickdarms  zu  diagnosti- 
sehen  und  therapeutischen  Zwecken.  Deutsch,  Arch,  fur  klin.  Med.,  Bd.  xxxiii, 
S.  235. 

■}■  Schnetter.  Zur  Behandlung  der  Darmverschliessungen.  Deutsch.  Arch,  fur 
klin.  Med.,  Bd.  xxxiv,  S.  638.— Rosenbach.     Berl.  klin.  Wochcnschr.,  1890. 


86  DISEASES  OP  THE  STOMACH. 

and  three  quarters  of  a  teaspoonful  of  tartaric  acid  are  each  dis- 
solved in  half  a  tumblerful  of  water ;  the  tartaric-aeid  solution  is 
given  first,  and  immediately  after  it  the  sodium  bicarbonate.  Eiegel, 
Osier,  Meinert,  and  many  others  have  never  seen  any  bad  effects 
from  this  method,  which  certainly  has  the  great  advantage  of  dis- 
pensing with  the  stomach  tube.  Should  the  results  be  unsatisfac- 
tory we  can  always  resort  to  the  inflation  of  air.]  For  these  rea- 
sons it  is  better  to  use  the  method  recommended  by  Euneberg,  * 
which  has  long  been  used  by  Oser  f  and  myself,  and  which  consists 
in  introducing  a  stomach  or  rectal  tube  and  then  insufflating  air 
with  the  double  bulb  of  a  spray  apparatus.  Frequently  there  are 
also  other  good  reasons  for  introducing  the  tube  in  a  given  case, 
and  this  does  away  with  any  objections  against  a  special  passage  of 
the  tube  with  its  accompanying  inconveniences,  although  the  latter 
are  really  too  insignificant  to  have  any  weight.  Euneberg  says  cor- 
rectly :  "  In  endeavoring,  for  example,  to  estimate  exactly  the  size 
and  situation  of  a  markedly  dilated  stomach  it  is  by  no  means  an 
easy  task  to  obtain  a  suitable  degree  of  distention  by  generating 
carbonic-acid  gas.  On  the  other  hand,  this  may  be  very  conven- 
iently and  easily  accomplished  by  this  method  of  pumping  in  air." 
The  same  is  true  of  the  intestines,  especially  of  the  transverse  colon. 
Any  excess  of  air  pumped  in  escapes  alongside  of  the  tube,  or  is  easily 
expelled  by  a  reactive  contraction  of  the  stomach  as  soon  as  the 
patient  experiences  a  marked  tension  of  that  viscus.  In  using  car- 
bonic-acid gas  the  reverse  usually  occurs,  since  the  irritation  of  the 
gas  causes  a  spasmodic  contraction  of  the  cardia,  so  that  the  patient 
must  exert  himself  more  vigorously  to  expel  it ;  furthermore,  the 
j)ylorus  may  relax  more  readily  than  the  cardia,  and  the  gas  may 
then  pass  on  into  the  small  intestines.  I  have  never  observed  the 
condition  described  by  Ebstein  as  insufiiciency  of  the  pylorus,  in 
which  the  gas  generated  in  the  stomach  passes  rapidly  into  the  duo- 
denum. I  believe  that  conditions  in  which  the  pylorus  is  not  re- 
laxed at  first,  but  only  during  the  generation  of  the  carbonic-acid 

*  W.  Runeberg.  Ueber  kiinstliehe  Aufblahung  des  Magens  und  des  Dick- 
darms  dureh  Einpumpen  von  Luft.  Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  xxxiv, 
S.  460. 

f  Oser.     Die  Neurosen  des  Magens.     Vienna,  1885,  S.  10. 


DISTEXTIOX  OF   STOMACH   WITH   WATER.  87 

ffas.  are  due  to  tlie  causes  above  mentioned.  It  is  true  Scliiitz  "^  has 
had  just  the  reverse  experience  of  observing  the  air  pumped  in 
escape  rapidly  into  tlie  intestine,  but  it  seems  to  me  that  this  was  an 
exceptional  case,  which  does  not  agree  with  the  experiences  of  Oser  f 
and  of  myself.  Inflation  of  the  stomach  and  intestines  may  be 
combined.  Behrens  :|:  lias  called  attention  to  the  value  of  the  latter 
method  for  detecting  tumors  which  might  be  present  in  the  abdom- 
inal cavity.  According  to  my  own  ex]^)erience,  the  quantity  of  aii* 
to  be  pumped  in  through  the  rectum  is  very  variable,  and  the  same 
is  true  of  the  distinctness  with  which  the  distended  coils  of  mtes- 
tines  may  be  seen.  I  have  always  been  struck  by  the  amount  of 
air  which  could  be  pumped  in  through  the  anus  without  again  escap- 
ing, providing,  of  cburse,  that  there  is  no  marked  accumulation  of 
f geces.  ^here  the  latter  exists,  and  in  strictures  and  stenoses  of 
the  lower  portion  of  the  intestine,  the  aii-  is  soon  expelled,  together 
with  foul-smelling  gases.  This  feature  I  have  repeatedly  found  in 
cases  of  compression  of  the  descending  colon  by  a  neoplasm.  If  we 
auscultate  the  abdominal  walls,  preferably  with  a  binaural  stetho- 
scope, while  the  air  is  being  jjumped  in,  we  can  accurately  follow 
the  advance  of  the  air  in  the  various  portions  of  the  intestines. 

3.  Distention  of  the  Stomach  with  Water, — A  somewhat  similar 
but  less  convenient  idea  was  embodied  in  the  plan  proposed  by 
Piorry,  but  made  especially  well  known  by  Penzoldt,*  to  deter- 
mine the  site  of  the  lower  border  of  the  stomach  by  filling  that 
viscus  ^vith  water.  As  water  sinks  to  the  lowest  part  of  the  stom- 
ach, in  a  sitting  or  standing  posture,  a  large  quantity  of  fluid  intro- 
duced into  the  organ  will  indicate  the  course  of  the  greater  curva- 
ture by  a  curved  hne  of  dullness  with  the  convexity  downward — 
providing  that  the  transverse  colon  contams  air :  and  by  pouring 
in  and  siphoning  out  larger  quantities,  about  one  litre  [quart],  we 
wiU  prevent  mistaking  it   for  neighboring   organs,  tumors,  etc., 

*  E.  Schutz.  "Wanderniere  und  Magenerweiteriing.  Prag.  med.  Wochenschr., 
January  14,  188ri. 

t  Oser.     Die  IJi-sachen  der  Magenerweitenmg.     Wiener  med.  Kiinik.  1881.  S.  4. 

X  0.  Bebrens.  Veber  den  Werth  der  kiinstlichen  Auftreibnng  de?  Dickdarms 
rait  Gasen  nnd  mit  Fliissigkeiten.  Gottingener  Inaugural  Dissertation.  Helm- 
stadt.  1886. 

*  Penzi'ldt.     Die  Magenerweiterung.     Erlangen,  1877. 

T 


88  DISEASES  OP   THE   STOMACH. 

having  a  dull  percussion  note.  Further  details  concerning  this 
method,  and  also  a  modification  proposed  by  Dehio,  will  be  dis- 
cussed while  speaking  of  dilatation  of  the  stomach.  [Chapter  YI]. 
In  this  connection  I  wish  to  make  some  remarks  upon  the  deter- 
mination of  the  situation  and  size  of  the  stomach. 

A  sufiicientlj  good  guide  for  the  situation  of  the  stomach  is  the 
greater  curvature ;  normally,  in  men,  when  the  stomach  is  moder- 
ately distended,  it  crosses  the  median  line  at  about  the  beginning  of 
the  lower  third  of  the  xipho- umbilical  hue— i.  e.,  the  distance  be- 
tween the  xiphoid  process  and  the  umbilicus ;  in  women,  it  crosses 
at  the  middle  of  this  line ;  *  in  either  case  it  is  above  the  umbilicus. 
It  is  immaterial  whether  this  is  determined  by  inflating  the  stomach 
with  air  or  carbonic-acid*  gas  to  map  out  the  area  of  tympanitic 
resonance,  or  by  gradually  filling  the  stomach  with  water  to  obtain 
the  lower  zone  of  dullness  which  separates  it  from  the  air-filled 
transverse  colon ;  it  is  also  immaterial  whether  these  procedures  are 
carried  out  while  the  patient  is  recumbent  or  standing  up  (prefer- 
ably with  the  body  bent  forward),  or  whether  ordinary  or  auscul- 
tatory percussion  is  employed.f  The  differences  which  are  obtained 
with  these  various  methods  are  always  less  than  the  great  individual 
variations  in  the  situation  and  size  of  the  stomach ;  it  is  sufficient  to 
remember  that  the  greater  curvature  ought  to  he  above  the  um- 
bilicus. In  a  careful  study  of  81  persons,  in  which,  unfortunately, 
those  having  gastric  disorders  have  not  been  separately  classified, 
Paean  owski  \  found  that  the  distance  of  the  lower  border  of  the 
stomach  above  the  umbihcus  in  the  left  parasternal  line  was  3  to  5 
centimetres  [1^  to  2  inches]  in  men  and  4  to  7  centimetres  [If  to 
2|-  inches]  in  women ;  when  the  stomach  was  moderately  distended 
with  carbonic-acid  gas  the  distance  between  the  highest  and  lowest 
point  in  the  zone  of  tympanitic  resonance  was  between  11  to  14 
centimetres  [4f  to  5f  inches]  in  men  and  only  10  centimetres  [4 

*  H.  Pacanowski.  Beitrag  zur  percutorische  Bestimmung  der  Magengrenzen. 
Deutseh.  Arch,  fiir  Idin.  Med..  Bd.  xl,  p.  342.— P.  Prednzzi.  La  percussione  dello 
stomacco.  Ri  vista  clin.,  1890,  No.  1.— G.  Kelling.  Ueber  die  Ermittelung  der  Magen- 
grosse.     Inang.  Dissert.,  Leipzig,  1890. 

t  Obrastzow.  Zur  physikalischen  Untersuehung  des  Magens  und  Derms. 
Deutseh.  Arch,  fur  klin.  Med.,  Bd.  xliii,  p.  417.  See  Chapter  VI  for  discussion  on 
changes  in  the  percussion  in  displacements  of  the  stomach  (Kernig). 

X  hoc.  cit. 


GASTROPTOSIS.  89 

inches]  in  women  ;  the  greatest  width  of  the  tympanitic  zone  was  21 
to  18  centimetres  [81  to  7^  inches]  respectively.  On  the  other  hand, 
the  greater  curvature  was  several  centimetres  below  the  uiAbihcus 
in  a  case  of  gastrectasis  and  one  of  atony,  and  consequently  the 
results  were  different  from  the  figures  given  above. 

My  o^vn  observations  agree  quite  well  with  these  results,  al- 
though, on  an  average,  I  have  found  the  distance  between  the 
greater  curvature  and  the  umbilicus  to  be  somewhat  less — i.  e., 
usually  between  2*5  to  4  centimetres  [1  to  If  inches].  At  all 
events,  it  may  be  accepted  as  a  rule  that  pathological  conditions 
exist  when  the  greater  curvature  hes  at  or  below  the  umbilicus. 
The  same  is  true  of  the  method  proposed  by  Pradezzi  and  others  to 
use  the  intersection  of  the  ninth  rib  and  the  left  mammillary  line 
as  a  guide  for  the  greater  curvature,  as  it  is  claimed  that  it  is  nor- 
mally subject  to  fewer  variations.* 

Downward  displacement  of  the  lower  border,  however,  does  not 
necessarily  indicate  an  increase  in  the  size  of  the  stomach,  since  the 
same  thing  occurs  in  downward  dislocation  of  the  stomach  (ffccs- 
troptosis  or  descensus  venl/piGuli)  or  when  the  stomach  assumes  a 
more  or  less  vertical  position,  so  that  the  course  of  the  greater  curv- 
ature is  almost  parallel  with  the  left  border  of  the  body. 

Both  of  these  conditions  will  be  revealed  by  distention  of  the 
stomach.  In  gastroptosis  the  organ  looks  like  a  distended  air  cush- 
ion which  lies  across  the  middle  of  the  abdomen.  Superiorly  it  is 
flattened  out  on  a  concave  line  which  represents  the  lesser  curva- 
ture ;  above  this,  in  the  epigastric  region,  there  is  a  depression  which 
gives  a  dull  note  on  percussion,  and  in  which,  as  stated  above,  the 


*  As  the  result  of  a  series  of  very  careful  investigations,  Obrastzow  (Joe.  cit.) 
comes  to  the  conclusion  that  the  situation  of  the  lower  border  of  the  stomach  is  di- 
rectly dependent  upon  the  build  and  general  nutrition  of  the  individual.  The  better 
these  are,  the  higher  will  the  greater  curvature  lie ;  while  the  poorer  these  are,  and 
the  older  the  individual,  the  nearer  it  will  approach  the  umbilicus.  In  men  as  well 
as  in  women  it  may  usually  be  found  in  the  lower  third  of  the  xipho-umbilieal 
line.  It  is  displaced  downward  by  pregnancy,  diseases  in  which  the  diaphragm  is 
pushed  downward  (emphysema,  pleuritis,  and  pneumothorax),  and  enlargement  of 
the  liver  and  spleen.  The  reverse  is  true  of  the  diseases  which  lessen  the  capacity 
of  the  abdominal  cavity.  Actite  and  chronic  diseases  of  the  stomach  (excepting 
gastrectasis  from  whatever  cause)  have  no  influence  upon  the  situation  of  the  lower 
curvature. 


90 


DISEASES   OF  THE  STOMACH. 


pancreas  may  at  times  be  palpated.  iTiferiorly,  the  greater  curva- 
ture may  be  distinguislied  below  tbe  umbilicus  as  a  curved  line 
with  its  convexity  downward.  Transillumination  of  the  stomach 
{vide  infra)  will  corroborate  this.  In  gastroptosis,  the  volume  of 
the  stomach,  as  a  rule,  remains  normal ;  but,  according  to  my  ex- 
perience, when  the  stomach  is  vertical  a  dilatation  is  always  present. 
This  is  well  shown  in  the  accompanying  drawing  (Fig.  Y).     In  such 


Fig.  7. — Vertical  situation  of  stomach  and  exposure  of  the  body  of  the  pancreas.  In  this 
case  the  dilatation  is  only  moderate ;  in  other  cases  it  may  be  so  marlied  that  the  greater 
curvature  reaches  the  symphysis. 

cases  the  lesser  curvature  may  be  seen  near  the  middle  line,  or  even 
to  the  left  of  it,  while  the  zone  of  gastric  tympanites  may  fill  the 
entire  left  side  of  the  abdomen ;  consequently  there  can  be  little 
doubt  as  to  the  size  and  situation  of  the  viscus. 

The  absolute  size  of  the  stomach  is  subject  to  very  great  differ- 
ences, even  under  normal  conditions,  which  are  independent  of  the 
height  of  the  individual. 

I  have  a  series  of  plaster  casts  of  stomachs  which  were  made  by 
filling  the  viscus  with  liquefied  tallow  after  it  had  been  removed 
from  the  body  and  tying  at  both  cardia  and  pylorus.     Matrices 


GASTROPTOSIS, 


91 


were  tlien  taken  from  the  casts  thus  formed,  and  the  plaster  models 
made  from  these.* 

One  can  most  thoroughly  be  convinced  of  the  well-known  fact 
of  the  variations  in  form  and  size  of  the  stomach  by  noting  that 


Fig.  8.  Fig.  9.  Fig.  10. 

[Fig.  8. — Cast  of  cylindriform  stomach  in  vertical  position.     Female.     Ziemssen.] 
[Fig.  9. — Cast  of  normal  stomach.     Female.     Ziemssen.] 
[Fig.  10. — Cast  of  dilated  stomach  in  vertical  position.     Female.     Ziemssen.] 

eight  or  ten  other  models  differ  a  great  deal,  although  all  of  them 
were  made  from  persons  of  about  the  same  size,  who  had  never 
during  life  complained  of  any  disturbance  of  digestion.  Besides 
the  simple  purse-shaped,  we  find 
stomachs  which  are  elongated,  al- 
most, indeed,  like  a  sausage,  and 
others  in  which — be  it  remembered, 
without  the  action  of  cicatricial  con- 
traction— a  marked  exaggeration  of 
the  so-called  antrum  pylori  (i.  e., 
the  lower  portion  lying  below  the 
pylorus)  [see  Fig.  10,  «]  has  almost 
caused  the  viscus  to  assume  the 
shape  of  an  hourglass.     Just  as  the  ,„     „     ^   ,   .         ,  j,    j-w  ^  . 

'^  ~  [Fig.  11. — Cast  of  a  markedly  dilated  stom- 

f  Orm,  so  varies   the    capacity  of   the         ach  tending  to  assume  vertical  position. 
,  -1  1  •   1,     •        J.1  Female.     Ziemssen. 1 

stomach,  which   m   these  prepara-  -' 

tions  was  always  determined  by  filling  them  with  water.    The  largest 


*  [Figs.  8,  9,  10,  and  11  are  from  photographs  of  some  of  these  plaster-of-Paris 
casts.  They  were  all  taken  at  the  same  distance  from  the  camera,  and  were  placed 
in  the  position  which  they  occupied  in  the  body.  The  difEerences  in  form,  position, 
and  size  have  thus  been  preserved. — Ed.] 


92  DISEASES  OP   THE  STOMACH. 

stomacli  lield  1,680  c.  c.  [f  §  xlvj],t]ie  smallest  only  250  c.  c.  [f  ^  viij]  ; 
between  these  limits  we  find  all  possible  variations. 

From  this  it  can  be  inferred  that  there  is  no  absolute  standard 
for  the  size  of  the  normal  stomach,  at  least  within  the  given  limits, 
and  that  its  capacity  by  no  means  bears  a  fixed  relation  to  the  size 
of  the  body.  We  may  find  a  very  large  stomach  in  a  comparatively 
small  individual,  and  vice  versa,  so  that  clinically  one  can  only 
speak  of  a  dilatation  under  the  restrictions  to  be  mentioned  later 
on  [see  Chapter  VI]. 

But  it  is  very  easy  to  determine  the  capacity  of  the  stomach  in 
the  living  subject  and  without  distending  it  with  water ;  it  may  be 
done  at  the  same  time  when  we  inflate  the  stomach  with  air  to  as- 
certain its  situation.  We  first  learn  the  size  of  the  compressing 
bulb  of  the  double  bulb  of  a  spray  apparatus,*  and  then  count  the 
number  of  times  we  must  compress  the  bulb  until  the  patient  indi- 
cates that  the  pressure  of  the  air  upon  the  gastric  walls  is  painful, 
and  can  thus  easily  calculate  the  volume  of  air  which  has  been 
inflated. 

Unfortunately,  however,  researches  which  have  been  made  under 
my  direction  by  Dr.  Kelling  have  shown  that ,  the  capacity  of  the 
stomach  in  one  and  the  same  individual  is  subject  to  quite  consider- 
able variations  at  different  times ;  or,  in  other  words,  varying  amounts 
of  air  must  be  pumped  in  at  different  times  to  produce  the  same 
pressure  within  the  stomach.  This  may  easily  be  ascertained  by 
attaching  a  manometer  to  the  stomach  tube  and  double  bulb  by 
means  of  a  T  tube ;  we  can  thus  determine  in  each  case  how  much 
air  had  to  be  pumped  in  in  order  to  obtain  the  same  pressure, 
or  we  can  ascertain  at  what  pressure  each  patient  complained  of 
pain  or  distention.  These  experiments,  which  it  is  self-evident 
must  be  performed  on  an  empty  stomach,  have  naturally  had  very 
varying  results,  because   the   factors   upon  which  they  depend — 

*  This  calculation  is  most  readily  made  thus :  A  tall,  graduated  cylinder  of  about 
200  c.  c.  [  I  vjss.]  is  filled  to  the  edge  with  water,  is  covered  air-tight  with  the  palm 
of  the  hand,  and  is  inserted  in  a  vessel  of  water.  The  tube  of  the  double  bulb  is 
placed  under  the  inverted  cylinder:  on  compressing  the  bulb,  the  air  will  rise  in  the 
cylinder  and  will  displace  as  much  water  as  represents  the  capacity  of  the  compres- 
sion bulb.  This  simple  procedure  can  be  carried  out  at  any  druggist's  shop.  The 
bulbs  which  I  usually  employ  hold  about  150  c.  c.  [  |  v]. 


THE   DEGLUTITION   MURMURS.  93 

namely,  the  tone  of  the  gastric  muscular  fibers,  the  situation 
and  fullness  of  the  intestines,  the  tension  of  the  abdominal  walls 
— are  different  at  different  times.*  However,  the  results  ob- 
tained with  inflation  will  always  enable  one  to  determine  whether  the 
stomach  is  small  or  large  or  abnormally  large,  or  whether  it  is  at 
the  same  time  displaced.  [For  further  details,  and  exact  methods  as 
to  size  and  situation  of  the  stomach,  see  Chapter  YI  on  Dilatation 
of  the  Stomach,  and  Chapter  XI  on  Gastroptosis.] 

Finally,  the  stomach  may  be  so  small  that  it  may  not  be  demon- 
strable, and  may  eventually  completely  disappear  behind  the  costal 
border  or  left  lobe  of  the  hver.  This  may  occur  either  in  total  car- 
cinomatous degeneration  of  the  stomach,  which  may  be  so  extreme 
that  the  organ  looks  like  a  loop  of  intestine,  or  in  obstruction  of  the 
oesophagus  when  the  stomach  does  not  have  the  normal  stimulation 
from  the  food,  and  hence  contracts  itself  as  much  as  possible. 
The  accompanying  figure  (Fig.  12)  is  a  typical  example  of  this  con- 
dition which  was  found  in  a  case  of  oesophageal  carcinoma. 

4.  The  Deglutition  Murmurs  {Schluchgerdusche)  as  diagnostic  aids. 
At  another  place  f  I  have  spoken  of  the  nature  and  character  of 


*  [These  results  have  been  disclaimed  by  Kelling.  Volkmann's  Sammlung 
klinische  Vortrage,  No.  144,  February,  1896,  p.  29. — Ed.] 

f  Ewald.  Klinik  der  Verdauungskrankheiten,  I.  Theil,  3te  Auflage,  pp.  67-70. 
[As  these  murmurs  are  quite  frequently  referred  to  in  the  following  pages,  this 
brief  extract  of  the  author's  views  as  to  their  nature  and  origin  has  been  added. 
At  the  beginning  of  swallowing,  a  murmur  is  propagated  from  the  pharynx  into  the 
oesophagus ;  this  sound  has  no  significance  whatsoever.  The  true  murmurs  are  the 
Durehsprifzgerdtisch  and  the  Durchpressgerdusch.  Ewald  thinks  it  much  better 
to  call  them  simply  the  first  and  second  murmurs  respectively.  The  first  murmur 
(Spritzgerdusch)  occurs  almost  immediately  after  the  beginning  of  deglutition,  and 
is  a  hissing  sound,  as  if  the  fluid  were  being  directly  squirted  into  the  stethoscope. 
Some  time  after,  usually  six  to  seven  seconds,  the  second  sou7id  (Pressgerdusch)  is 
heard;  this  is  a  series  of  tones  rapidly  following  one  another,  either  gurgling,  cluck- 
ing, sprinkling,  or  splashing.  These  murmurs  are  heard  only  near  the  cardia  ;  the 
best  site  is  just  below  the  xiphoid  cartilage;  this  at  once  distinguishes  them  from 
the  sounds  transmitted  from  the  pharynx,  which  may  be  heard  all  along  the 
oesophagus.  The  first  sound  is  only  heard  rarely;  its  occurrence  is  said  to  denote 
a  relaxation  of  the  cardia,  and  the  direct  passage  of  the  food  into  the  stomach ;  the 
second  is  quite  constant,  and  is  absent  only  when  the  first  is  heard.  Its  nature  is 
not  so  evident;  some  (Kronecker)  claim  that  it  is  due  to  the  audible  vibrations  of 
the  cardia  which  are  caused  by  the  passage  of  the  food  over  it ;  others  (Zencker. 
Quincke,  Ewald,  Dirksen)  assert  that  it  is  simply  a  result  of  the  pressing  through 
of  the  air  which  has  been  swallowed  with  the  food. 

These  sounds  were  first  mentioned  in  1864  by  Natanson,  and  were  carefully 


94 


DISEASES  OP  THE  STOMACH. 


these  murmurs,  and  shall  simply  say  here  that  they  give  no  positive 
indications  in  the  diagnosis  of  gastric  diseases.  Meltzer  *  claimed 
that  the  so-called  SchhtckgerdusGh  was  due  to  a  relaxation  of  the 


i--na 


Fig.  12. — Contraction  of  the  stomach  in  a  case  of  cancer  and  stenosis  of  the  oesophagus. 

cardia,  and  occurred  as  a  specific  symptom  of  old  syphilis,  phthisis 
accompanied  by  mild  vomiting,  neuroses  of  the  cardia,  etc.     The 


studied  by  Zencker  and  also  by  Meltzer.     The  literature  of  the  subject  may  be 
found  in  Ewald,  loc.  cit.,  p.  93. — Ed.] 

*  Meltzer.     Schhickgerausche  im   Scorbiculus  cordis  und  ihre  physiologische 
Bedeutung.     Centralbl.  f.  d.  med.  Wissensch.,  1883,  No.  1. 


GASTROSCOPY.  95 

inconstancy  of  tlie  phenomenon  was  sliown  by  Dirksen  *  and  myself. 
I  have  never  observed  any  constant  and  characteristic  change  in  the 
intensity  or  quahty  of  these  murmurs,  either  in  paralytic  spinal 
lesions  or  dilatation  of  the  stomach,  or  in  any  other  condition  which 
at  first  sight  might  seem  to  include  this  phenomenon.  On  the 
other  hand,  typical  and  of  diagnostic  value  is  the  absence  of  the 
deglutition  murmurs  in  complete  or  almost  complete  closure  of  the 
cardia,  whether  the  obstruction  be  above  or  below  the  cardia.  Yet 
this  negative  proof  must  be  determined  positively  by  repeated  ex- 
aminations, since  the  murmur  is  now  and  then  absent  in  healthy 
persons. 

5.  Another  method  of  examination  requiring  a  few  words  is 
that  inaugurated  chiefly  through  the  labors  of  Mikulicz  [and  Rosen- 
heim]— gastroscopy,  or  the  direct  visual  examination  of  the  mucous 
membrane  of  the  stomach  with  a  specially  adapted  instrument,  the 
gastroscope.  Unfortunately,  the  simple  mention  of  this  author's 
name  almost  exhausts  the  literature  of  the  subject,  for  the  instru- 
ment, as  constructed  by  Leiter  (of  Vienna),  is  so  expensive  and  at 
the  same  time  so  difficult  to  manipulate,  unless  both  patient  and 
physician  have  been  well  trained,  that  its  use  has  been  very  limited. 
The  results  which  Mikulicz  f  obtained  in  carcinoma  of  the  pylorus 
are  of  diagnostic  interest.  In  the  normal  stomach  the  pylorus  ap- 
pears as  a  long  slit  or  a  triangular,  oval,  and  often  a  circular  open- 
ing, surrounded  by  a  ring  of  bright-red  folds  and  projections  of 
mucous  membrane,  which  are  in  active  motion  and  show  an  infinite 
number  of  changes  of  form.  But  in  neoplasms  at  the  pylorus  this 
region  is  smooth,  pale,  without  the  above-described  folds  and  pro- 
jections, and  absolutely  motionless.  This  would  thus  be  a  valuable 
aid  in  diagnosis,  had  not  Pribram  :};  reported  a  case  of  pyloric 
carcinoma  —  at  all  events,  without  gastroscopic  examination — in 
which  there  were  active  movements  of  the  tumor ;  i.  e,,  a  change 
in  its  size  synchronous  with  active  contractions  of  the  whole 
stomach. 

*  H.  Dirksen.  Beitrag  zur  Lehre  von  den  Schluckgerausehen.  Inaug.  Dissert., 
Berlin,  1885. 

\  Wiener  med.  Wochensehrift,  33te  Jahrgang,  S.  748. 

X  Pribram.  Zur  Semiotik  des  Pyloruscarcinoms.  Prager  med.  Wochensehr., 
1884,  S.  53. 


96 


DISEASES  OF  THE  STOMACH. 


[Rosenlieim  *  has  devoted  much  time  to  perfecting  the  gastro- 
scope,  and  has  devised  two  instruments  for  this  purpose.  He  claims 
that  this  method  is  of  great  service  in  the  early  diagnosis  of  cancer  ; 
but,  as  he  himself  admits,  this  method  is  adapted  only  for  few 
cases,  as  much  experience  and  time  are  required  to  use  the  in- 
strument. 

It  may  be  of  interest  to  note  that  the  interior  of  the  stomach  has 
also  been  photographed  by  Kuttner.f] 

6.  The  gastrodiaphane,  which  was  first  suggested  by  Einhorn,:}: 
and  later  by  Heryng  and  Eeichmann,*  is  an  entirely  different  instru- 
ment from  the  gastroscope,  since  the  main  object  of  the  procedure 
is  to  transilluminate  the  gastric  and  abdominal  walls.     This  is  most 

readily  accomplished  with  Ein- 
horn's  instrument  [Fig.  13], 
which  consists  of  a  flexible  rub- 
ber stomach  tube,  at  the  end  of 
which  is  a  small  Edison  incan- 
descent light  about  the  size  of 
a  small  hazelnut.  The  conduct- 
ing wires  run  through  the  tube 
and  are  connected  with  a  switch 
after  they  leave  it ;  the  lamp 
is  made  of  strong  crystal  glass. 
There  is  little  danger  of  over- 
heating the  lamp,  as  the  stom- 
ach must  contain  some  water 
before  the  instrument  is  intro- 


[FiG.  13.— EiL_. 


.  jdiaphane.] 


duced,  and,  furthermore,  the  current  need  be  turned  on  but  for  a  very 
short  space  of  time.  [The  instrument  should  be  introduced  on  an 
empty  stomach,  or  the  stomach  should  be  washed  out  if  it  contains 
food.     One  or  two  glasses  of  water  are  taken  before  inserting  the 


*  [Full  details  on  this  snbject  will  be  found  in  Rosenheim's  Krankheiten  der 
Speiserohre  und  des  Magens,  2te  Auflage,  1896,  pp.  550-578. — Ed.] 

t  [Kuttner.     Deutsch.  med.  Wochenschr.,  1891,  p.  1311.— Ed.] 

X  Einhorn.  Ueber  Gastrodiaphanie,  N.  Y.  med.  Monatschr.,  1889 ;  Berl.  klin. 
Wochenschr.,  1892,  No.  51. 

«  Heryng  und  Reichmann.  Ueber  electrische  Magen-  und  Darmdurchleuchtung. 
Therap.  Monatshefte,  March,  1892. 


GASTRODIAPHANY. 


97 


instrument.  Kuttner  and  Jacobson  recommended  taking  2  to  3 
pints.]  The  examination  is  best  conducted  in  a  darkened  room  [and 
in  the  standing  position].  If  the  abdominal  walls  are  sufficiently 
translucent — which,  unfortunately,  is  too  frequently  not  the  case — 
brightly  illuminated  or  rather  transilluminated  areas  will  be  seen 
upon  the  abdominal  walls.     These  areas  have  various  sizes  and  situ- 


II  ^<r,y  1  I  v/ 

Fig.  14. — Gastrodiaphanic  picture  in  normal    Fig.  15.— Gastrodiaphanic  picture  in  dilated 
stomach.  stomach. 


Fig.  16.^Gastrodiaphanic  picture  in 
gastroptosis. 


Fig.  17. — Gastrodiaphanic  picture  in 
gastroptosis. 


ations,  as  may  be  seen  in  the  accompanying  figures  (Figs.  14  to  lY), 
which  have  been  reproduced  from  Einhorn's  paper,  and  may  have 
some  diagnostic  value. 

An  extended  use  of  this  method  will  be  precluded  by  the  difficul- 
ties incidental  to  the  nature  of  the  apparatus  and  obtaining  the 
requisite  electricity,  and  especially  by  the  fact  that  these  diagnostic 
results  may  be  reached  by  our  ordinary  methods. 


98  DISEASES   OF   THE  STOMACH. 

[This  method  has  been  carefully  studied  t>y  Kuttner  and  Jacob- 
son,  Pariser,  Meltzing,  Martins,  Meinert,  and  Kelling.*  Kuttner 
and  Jacobson  claim  that  the  form  and  situation  of  the  transillumi- 
nated  area  is  not  alone  sufficient  to  make  a  differential  diagnosis  be- 
tween dilatation  and  displacement  of  the  stomach.  They  lay  stress 
upon  the  absence  of  respiratory  changes  in  diagnosticating  the  latter. 
This  is  denied  by  Meltzing ;  this  observer  also  found  that  the  size 
of  the  stomach  as  shown  by  transillumination  is  larger  than  is 
shown  by  percussion ;  thus  he  claims  that  even  the  empty  stomach 
may  reach  as  low  as  the  umbilicus.  Kelling  shows  that  the  illu- 
minated area  need  not  necessarily  correspond  to  the  part  of  the 
stomach  which  it  overlies,  for  it  may  be  too  small  if  filled  coils  of 
intestines  intervene,  or  if  the  lamp  is  too  far  removed  from  the 
abdominal  parietes ;  or  it  may  be  too  large  if  adjacent  empty  coils  of 
intestines  are  also  transilluminated.  He  also  shows  by  experiments 
on  the  cadaver  that  the  light  may  penetrate  the  transverse  colon 
obliquely,  and  thus  lead  one  to  suppose  that  the  empty  stomach  was 
at  the  umbilicus,  while  in  reality  it  was  behind  the  liver. 

Furthermore,  the  diagnosis  of  tumors  in  the  anterior  wall  of  the 
stomach,  as  claimed  by  Einhorn,  is  considered  doubtful  by  Riegel  f 
and  others.] 

The  Technique  of  the  Treatment  of  Stomach  Diseases. — Of  the 
numerous  methods  from  time  to  time  proposed  for  washing  out  the 
stomach  or  irrigating  its  mucous  m^embrane,  the  best  is  the  simple 
si23hon  method,  concerning  which  we  may  speak  as  of  the  expres- 
sion method,  sim,pl6x  veri  sigilliim.  A  glass  funnel  is  attached  to 
the  free  end  of  the  stomach  tube  by  means  of  a  piece  of  rubber 
tubing  about  one  metre  [one  yard]  long,  and  by  alternately  raising 
and  lowering  the  funnel  the  stomach  may  be  filled  or  emptied.  The 
simple  siphon  action  is  all  that  is  needed,  since,  with  very  few  ex- 
ceptions, we  can  undertake  the  operation  at  a  time,  or  after  such 
meals,'  when  there  is  no  danger  of  having  the  openings  of  the  tube 

*  [Kuttner  und  Jacobson.  Berl.  klin.  Woehenschr.,  1893,  Nos.  39  and  40.— 
Pariser,  ibid.,  1892,  No.  32.— Meltzing.  Zeitschr.  fur  klin.  Med.,  Bd.  sxvii,  Heft  3 
und  4— Martius.  Centralbl.  fiir  innere  Med.,  1895,  No.  49.— Meinert,  ibid.,  1895, 
No.  49.— Kelling.  Volkmann's  Sammlung  klinische  Vortrage,  No.  144,  February, 
1896,  p.  16.— Ed.] 

f  [Riegel.     Krankheiten  des  Magens,  1896,  p.  37. — Ed.] 


TECHNIQUE   OP   LAVAGE. 


99 


plugged ;  and  even  if  small  pieces  of  meat  and  similar  substances 
are  aspirated  into  the  eyelets,  they  can  easily  be  dislodged  by  hold- 
ing the  funnel  high  up.  I  consider  it  entirely  irrelevant  whether 
we  use  a  continuous  stream  with  a  double-current  tube  or  Rosen- 
heim's douche,  described  on  page  Y,  or  whether  we  till  and  empty 
the  stomach  alternately ;  if  anything,  I  prefer  the  latter,  since  the 
rapid  raising  and  depressing  of  the  fun- 
nel agitates  the  fluid  in  the  stomach 
more  forcibly,  and  mucus  and  other 
solid  substances  caught  in  the  folds  of 
the  mucosa  may  be  more  easily  re- 
moved mechanically.  I  prefer  to  use 
a  large  glass  funnel  of  about  two  litres 
[two  quarts]  capacity,  with  a  diam- 
eter of  20  centimetres  [8  inches]  ;  this 
is  attached  to  a  rub- 
ber tube  of  suitable 
length,  which  is  joined 
to  the  upper  end  of 
the  stomach  tube  [by 
a  small  piece  of  glass 
tubing].*  The  funnel 
rests  in  a  wooden 
frame  (Fig.  18)  on  the 

floor  and  is  here  filled  with  the  requisite  amount  of  water  or 
other  fluid  used,  and  is  then  raised  to  a  height  suitable  to  ob- 
tain the  amount  of  pressure  desired.  The  water  escapes  from 
the  various  openings  in  the  tube  as  from  a  sprinkler,  so  that,  by 

*  [A  small  piece  of  glass  tubing,  the  caliber  of  which  is  somewhat  smaller  than 
that  of  the  stomach  tube,  is  very  convenient  for  connecting  the  latter  with  the 
tubing  attached  to  the  funnel ;  through  it  we  may  also  see  the  nature  of  tlie  fluid 
raised  from  the  stomach,  and  can  also  readily  determine  when  it  comes  up  perfectly 
clear.  It  is  quite  important  to  select  the  proper  rubber  tubing  for  this  purpose. 
The  best  kind  is  pure  gum  tubing,  the  caliber  of  which  is  slightly  larger  than  that  of 
the  stomach  tube.  The  advantages  of  this  tubing  are,  that  by  stripping  the  tube 
outward  we  may  obtain  sufficient  aspiration  to  start  the  siphonage  ;  or,  if  the  tube 
is  plugged,  we  may  often  dislodge  the  obstruction  by  stripping  the  tube  in  the 
reverse  direction.  These  minor  but  nevertheless  important  details  of  the  use  of 
the  tube  I  have  discussed  in  the  Technique  of  Obtaining  Stomach  Contents,  New 
York  Polyclinic,  August,  1894.— Ed.] 


Fig.  18. — Stand  for  holding  funnel  of  stomach  tube. 


100 


DISEASES  OP   THE  STOMACH. 


gradually  witlidrawing  the  tube  a  little,  the  various  portions  of  the 
stomach  may  be  successively  irrigated.  To  siphon  the  water  out  of 
the  stomach,  the  funnel  is  again  placed  in  the  wooden  frame,  and 
thus  any  foreign  substances  that  may  he  present  Tna/y  rise  in  it,  and 
can  be  obtained  for  examination  if  desired.  [To  allow  the  fluid  to 
accumulate  in  the  funnel  before  throwing  it  away  into  a  pail  is  a 
point  that  is  usually  neglected.  In  this  way  exfoliated  pieces  of 
mucous  membrane,  bits  of  tumor  tissue,  blood  clots,  etc.,  may  be 
obtained,  when  under  the  ordinary  method  they  would  doubtlessly 
escape  observation].  If  one  is  alone,  this  technique  is  much  more 
convenient  than  to  work  with  a  small  funnel.  For  consultation 
practice  out  of  the  office,  I  use  a  small  hard-rubber  funnel  of  about 
300  c.  c.  [f  5  x]  capacity. 

Siphonage  of  the  stomach  by  elevating  and  depressing  a  funnel 
can  not  be  done  by  the  patient  alone.  Yet  in  many  cases  it  is  es- 
sential that  the  patient  should 
wash  out  his  own  stomach ; 
the  first  requisite  is,  of  course, 
to  learn  to  introduce  the  tube 
himself,  a  manipulation  which 
most  patients  acquire  very 
readily.  Here,  too,  the  sim- 
plest method  will  suffice.  For 
siphonage,  the  following  will 
be  found  to  be  convenient : 
One  extremity  of  the  horizon- 
tal portion  of  a  glass  T  tube 
\_C,  Fig.  19]  is  connected  with 
the  stomach  tube  [A']  ;  the 
other  extremity  is  joined  to  an 
irrigator  by  means  of  a  soft- 
rubber  tube  [Z>],  a  hard-rubber 
stopcock  *  intervening ;  to  the 


[Fig.  19.- 


-From  Pepper's  System  of  Medicine 
(al'ter  Leube).] 


free  end  of  the  vertical  portion  is  attached  a  rubber  tube  \_E'\  about 
one  metre  [one  yard]  long.    The  patient  sits  near  the  irrigator,  which 

*  [This  is  not  essential ;  it  may  be  replaced  by  a  pinchcock  placed  on  the  tub- 
ing {d) ;  it  will  also  be  found  convenient  to  have  one  upon  e. — Ed.] 


TECHNIQUE   OP   LAVAGE. 


101 


has  previously  been  filled  and  placed  at  a  suitable  lieiglit ;  the  tube 
is  introduced  into  the  stomach  while  the  stopcock  is  kept  closed, 
and  the  open  end  of  the  rubber  tube  [e]  from  the  vertical  piece  of 
the  T  tube  is  compressed  with  the  fingers  of  one  hand.  With  the 
other  hand  he  then  opens  the  stopcock  after  the  tube  is  in  the 
stomach,  and  then  allows  a  suflacient  quantity  of  fluid  to  pass  into 
the  stomach.  As  soon  as  he  feels  the  distention  the  stopcock  is 
closed,  and  the  fingers  are  taken  off  the  vertical  tube  ;  this  allows 
the  fluid  to  be  siphoned  from  the  stomach.  By  repeating  this  the 
stomach  may  be  filled  and  emptied  as  often  as  desired.  Many  pa- 
tients become  very  skillful,  and  often  do  not  know  when  to  stop,  so 
that  finally  they  may  even  abuse  it.  Numerous  cases  of  this  kind 
can  be  found  reported,  especially  in  French  literature. 

[Recently  a  number  of  instruments  have  been  devised  for  lavage 
of  the  stomach.  Of  these  I  shall  only  mention  Hemmeter's  recur- 
rent tube*  and  Turck's  "pneumatic  force  irrigator." f    Hemmeter's 


[Fig.  20.— Hemmeter's  recurrent  stomach  tube  for  continuous  lavage.] 

apparatus  (Fig.  20)  consists  of  a  large  glass  jar,  E,  which  is  connected 
with  the  stomach  tube  by  means  of  a  hard-rubber  attachment,  A 
being  the  inlet  and  C  the  outlet.  The  stomach  tube  consists  of  one 
tube  within  the  other,  the  inlet  tube  being  shorter  than  the  outlet 
tube.     The  water  flows  along  B  and  enters  the  stomach  at  /;  it 


*  [Hemmeter.     N.  Y.  Medical  Journal,  December  28,  1895.— Ed.] 
f  [Turck.     Medical  News,  March  21,  1896.— Ed.] 


102  DISEASES  OP  THE  STOMACH. 

escapes  bj  a  number  of  openings  at  F^  and  is  conducted  to  a  pail 

Turck's  instrument  is  a  complicated  apparatus  for  using  hot  and 
cold  water  alternately  as  a  needle  douche  for  the  stomach.] 

If  one  desires  to  spray  the  interior  of  the  stomach  in  the  hope 
of  thus  getting  special  results,  Einhorn's  gastric  spray*  may  be 
used.  It  consists  of  a  specially  constructed  recurrent  stomach  tube 
with  a  spray  tip,  which  is  attached  to  the  hard  rubber  tube  of  the 
spray  apparatus.  It  is  to  be  introduced  into  the  empty  stomach.  I 
fail  to  see  how  any  special  benefits  can  be  obtained  from  it,  [Ein- 
horn  uses  this  instrument  for  producing  disinfection,  astringent 
effects,  and  analgesia.  Benedict  f  uses  a  menthol  spray  through 
the  stomach  tube  in  fermentative,  painful,  or  catarrhal  con- 
ditions.] 

Electricity  may  be  applied  to  the  stomach  either  by  placing 
both  electrodes  on  the  anterior  abdominal  wall,  or  by  introducing 
one  of  them  into  the  stomach  and  closing  the  current  by  means  of 
another  electrode  upon  the  abdominal  wall,  the  latter  electrode, 
according  to  well-known  physical  laws,  ^  having  as  large  a  cross- 
section  as  possible.  It  is  not  proven  that  contraction  of  the  gastric 
muscular  fibers  may  be  obtained  by  percutaneous  faradization.  The 
immediate  effect  is  only  a  contraction  of  the  abdominal  muscles,  the 
recti,  obliqui,  etc.  ;  pressure  is  thus  exerted  upon  the  stomach, 
which,  however,  would  hardly  be  interpreted  as  a  true  contraction 
of  the  stomach.  On  the  contrary,  the  gastric  contents  are  com- 
pressed ;  this  occurring  while  the  sphincters  are  closed  might 
even  produce  the  injurious  effect  of  distending  the  walls  of  the 
stomach. 

Hence  it  is  much  better  to  stimulate  the  gastric  muscular  fibers 
directly.  The  old  stomach  electrodes  had  the  disadvantages  of  be- 
ing diflicult  to  introduce,  and  of  causing  the  patient  much  discom- 
fort if  they  were  kept  in  place  for  a  long  time.     Eiuhorn  *  has 

*  Einhorn.    N.  Y.  Medical  Journal,  September  17,  1892. 

f  [Benedict.     International  Medical  Magazine,  September,  1894. — Ed.] 
X  Vide    C.    Rieger.      Grundriss    der    medicinischen    Eiectricitatslehre,    Jena, 
1887. 

#  Einhorn.    New  Method  for  Direct  Electrization  of  the  Stomach.     N.  Y.  Medi- 
cal Record,  May  9,  1891,  p.  530.    [Also,  Therapeutic  Results  of  Direct  Electrization 


ELECTRIZATION   OF   THE  STOMACH.  103 

partly  remedied  these  defects  witli  his  deglutable  electrode.  It  con- 
sists of  an  ovoid  perforated  hard-rubber  capsule  about  the  size  of 
an  almond ;  within  is  a  button  electrode  of  copper  or  brass  which  is 
connected  with  a  very  delicate  wire  covered  with  a  fine  rubber  tube. 
The  accompanying  drawing  (Fig.  21)  represents  the  instrument  in 
its  natural  size.  The  meth- 
od is  as  follows :  "  The  pa- 
tient drinks,  best  while  fast- 
ing, one  or  two  glasses  of 
water  ;    after    opening    the 

mouth  widely  the   capsule  is  ^m.  21.-Deglutable  stomacli  electrode. 

placed  far  back  on  the  root 

of  the  tongue,  and  the  patient  is  told  to  swallow.  He  again  drinks 
some  water,  and  the  electrode  finds  its  way  into  the  stomach  with- 
out further  assistance.  The  circuit  is  closed  by  means  of  a  flat  elec- 
trode placed  upon  the  abdomen.  But  since  many  persons  can  not 
swallow  the  capsule,  or,  if  swallowed,  it  frequently  stays  in  the 
oesophagus,  I  have  drawn  the  wire  through  a  somewhat  larger  rub- 
ber tube,  the  walls  of  which  are  1^  millimetres  [-06  inch]  thick, 
something  like  a  ]!Telaton  catheter,  JSTo.  13.  This  small  instru- 
ment can  be  readily  introduced  in  the  same  way  as  a  stomach  tube, 
and  yet  is  delicate  enough  to  be  readily  tolerated  for  some  time  in 
the  mouth  or  stomach. 

[Although  Einhorn  in  his  various  papers  states  that  he  has  abso- 
lutely no  trouble  in  introducing  his  electrode,  yet  I  must  confess  that 
my  experience  agrees  with  that  of  Ewald.  My  own  method  of 
overcoming  the  difficulty  is  to  take  a  braided  silk  oesophageal  bougie, 
No.  10  or  12  F.,  cut  o£E  the  top,  and  draw  the  insulated  wire 
through  the  hollow  bougie  after  having  flattened  the  connecting 
end  piece  of  the  electrode.  Such  electrodes  are  very  readily 
introduced  and  are  easily  borne  by  the  patients.  It  is  very  im- 
portant to  ascertain  beforehand  whether  the  capsule  is  firmly 
attached  to  the  electrode,  since  the  conducting  wires  are  so  thin 
that  they  break  very  readily.  It  has  once  happened  to  me 
that  the   capsule  broke   off  inside   the    stomach.      !N^o   harm   was 

of  the  Stomach,  ibid.,  January  30  and  February  6,  1893,     N.  Y.  Medical  Journal, 
July  8,  1893.— Ed.] 
8 


104  DISEASES   OP   THE   STOMACH. 

done,  as   the   capsule   was   passed  in  tlie   fseces    on    tlie   follow- 
ing day. 

.  Stockton  *  lias  devised  a  very  useful  gastric  electrode.  Turck  f 
lias  modified  his  gyromele  so  that  it  may  be  used  as  a  bipolar  gastric 
electrode.  Wegele's  electrode  :j:  is  a  thin  spiral  wire  tipped  with  a 
small  knob ;  it  can  be  introduced  through  an  ordinary  stomach  tube.] 
In  this  way  we  can  at  any  moment  ascertain  whether  the  cur- 
rent is  passing  from  the  stomach  to  the  abdominal  parietes,  as 
shown  by  the  contractions  of  the  latter.  The  only  question  is 
whether  at  the  same  time  there  are  also  active  contractions  of  the 
stomach.  I  have  recently  made  experiments  on  a  woman  with  a 
gastric  fistula  to  demonstrate  this.  A  small  electrode  and  the  tube 
of  a  manometer  were  introduced  into  the  fistula,  and  the  current 
closed  by  placing  an  electrode  on  the  sternum.  Each  time  the  cur- 
rent was  closed  the  fiuid  in  the  manometer  rose,  proving  that  pres- 
sure had  been  exerted  on  the  contents  of  the  stomach.  However, 
there  was  always  a  simultaneous  although  slight  retraction  of  the 
abdominal  muscles  ;  it  was  not  certain  whether  this  was  due  to  an 
active  contraction,  or  whether  it  was  caused  passively  on  account  of 
the  adhesions  to  the  abdominal  walls,  left  after  the  operation  on  the 
stomach.  The  experiment  was  therefore  repeated  on  a  patient  with 
atony  of  the  stomach.  A  thin  manometer  tube  was  inserted  into 
the  stomach  per  os  alongside  of  the  electrode.  Here  also  there  was 
a  distinct  increase  of  pressure,  although  there  was  no  contraction  of 
the  abdominal  muscles.  There  can  therefore  be  no  doubt  that  the 
muscular  fibers  of  the  stomach  are  directly  stimulated  by  the  intra- 
gastric faradization,  and  that  the  same  beneficial  effects  are  produced 
upon  them  which  we  know  occurs  elsewhere  after  faradization.  At 
all  events,  I  am  well  satisfied  with  the  results  obtained  in  quite  a 
large  number  of  patients  whose  condition  was  susceptible  of  im- 
provement. Baraduc*  is  almost  extravagant  in  his  praises  of 
"  electrization  interstomacale  et  la  galvanisation  du  grand  sympa- 
thique  au  cou." 

*  [Stockton.    K  y.  Medical  Journal,  July  30,  1892,  p.  138.— Ed.] 
f  [Turck.     Medical  News,  February  29,  1896,  p.  240.— Ed.] 

i  [Wegele.     Therapeut.  Monatshefte,  April,  1895.— Ed.] 

*  Baraduc.     Journ.  de  la  Societe  sclent.,  1891,  No.  10.  p.  97. 


ELECTRIZATION  OF  THE  STOMACH.  105 

Before  introducing  the  electrode  the  patient  must  drink  one  or 
two  glasses  of  water,  or,  if  the  stomach  is  much  dilated,  it  is  filled 
with  water  through  the  tube.  The  current  of  electricity  is  thus 
conducted  through  the  water  to  all  parts  of  the  stomach  which  are 
submerged. 

The  entire  digestive  tract  may  be  electrized  by  having  one  elec- 
trode in  the  stomach  and  the  other  in  the  rectum,  the  an  electrode 
being  introduced  after  having  cleansed  the  intestines  with  an  enema. 
Schillbach*  tried  this  method  on  rabbits  without  observing  any 
effect,  but,  as  it  appears^  neglected  the  preliminary  cleansing  of  the 
intestines.  In  several  cases  of  atony  of  the  bowels,  combined  with 
a  moderate  dilatation  of  the  stomach,  I  have  obtained  surprising  re- 
sults, but  in  others  none  whatever. 

A  series  of  investigations  has  already  been  made  to  show  the 
possibility  of  influencing  the  stomach  with  the  electric  current ;  for 
example.  Yon  Ziemssen  and  Caragiosiadis,f  Bocci,:}:  and  others.  Ac- 
cording to  these  observations,  the  external  application  of  the  elec- 
trodes causes  only  moderate  contractions,  which  are  of  very  doubt- 
ful therapeutic  value  ;  the  constant  current  produces  nothing  more 
than  a  localized  contraction.  The  induced  current,  especially  when 
it  is  applied  directly  to  the  mucous  membrane,  is  more  powerful, 
and  may  cause  the  secretion  of  gastric  juice  or  mucus,  as  Bocci  has 
shown  on  a  dog  with  a  gastric  fistula.  Yon  Ziemssen  *  says  that  in 
dogs  the  direct  passage  of  a  powerful  current  of  both  kinds  increases 
the  secretion  of  gastric  juice.  According  to  Allan  A.  Jones,  ||  an 
increase  of  the  secretion  of  HCl  can  not  always  be  demonstrated  on 
human  beings.  Eegnard  and  Loye  ^  observed  the  same  thing  in  an 
executed  criminal  whose  vagi  were  stimulated  by  an  electric  cur- 


*  E,  Schillbach.  Studien  iiber  den  Einfluss  der  Electricitat  auf  den  Darm. 
Virehow's  Archiv,  Bd.  cix,  S.  284. 

f  Caragiosiadis.  Die  locale  Behandlung  der  Gastro-ectasie  mit  dem  elektrisehen 
Strom.     Inaug.  Dissert.,  Munich,  1878. 

X  Bocci.  Elettricita  nello  stomaco  dell'  animale  e  dell'  uorao.  Lo  sperimentale. 
1881,  p.  561. 

*  Von  Ziemssen.  Ueber  die  physikalische  Behandlung  chronischer  Magen-  und 
Darmkrankheiten.     Klinische  Vortrage,  xii,  Leipzig.  1888. 

II  A.  A.  Jones.     The  Influence  of  Direct  Electrization  upon  Gastric  Secretion. 
N.  Y.  Medical  Record,  vol.  xxxi,  p.  677, 
^  Quoted  by  Von  Ziemssen,  loc.  cit. 


106  DISEASES  OP  THE  STOMACH. 

rent  forty-five  minutes  after  Ms  death.  The  experiments  conducted 
by  Sievers  and  myseK  showed  positively  that  faradization  of  the 
abdominal  wall  with  a  strong  current  and  broad,  flat  electrodes  has 
a  decided  effect  on  the  stomach.  In  many  persons  on  whom  the 
salol  test  was  tried  for  this  purpose  it  was  found  that  the  reaction 
in  the  urine  occurred  earlier  than  usual,  and  hence  the  salol  must 
have  been  carried  on  into  the  intestines  more  rapidly  as  the  result 
of  more  powerful  contractions  of  the  stomach. 

There  is  a  good  deal  of  clinical  evidence  of  the  beneficial  effects 
of  the  constant,  but  more  especially  of  the  induced,  current.  Many 
reliable  writers  agree  on  this  point,  as  Kussmaul,  Leube,  Fiirstner, 
Burkart,  Stockton*  [Einhorn,  Brock  f],  and  others.  Even  Yon 
Ziemssen  claims  good  results  from  the  percutaneous  electrization  of 
the  stomach  with  large  electrodes  of  about  500  to  600  square  centime- 
tres [about  80  to  100  square  inches]  area,  and  strong  currents  com- 
bined with  a  brief  f  aradic  brushing  of  the  skin  of  the  abdomen,  chest, 
and  back  for  two  to  three  minutes.  As  the  result  of  this  there  is  a 
feeling  of  warmth  and  invigoration,  marked  improvement  of  the  appe- 
tite, and  decidedly  increased  digestive  activity.  I  can  corroborate 
all  this.  For  example,  patients  with  nervous  anorexia  frequently  eat 
their  food  with  relish  and  digest  it  fairly  well  immediately  after  the 
application  of  electricity.  I  have  had  excellent  results  in  patients 
with  nervous  anorexia,  and  can  also  report  good  effects  upon  the 
movements  of  the  bowels.  Unfortunately  the  results  of  electric 
treatment  are  very  variable  and  inconstant ;  thus  Pepper,  :j:  in  a  case 
of  pyloric  cancer  with  dilatation  and  visible  peristalsis,  could  not  in- 
crease the  latter  either  with  a  faradic  or  a  constant  current,  but 
could  only  cause  a  contraction  of  the  abdominal  muscles. 

[Although,  as  shown  above,  much  clinical  evidence  has  been 
accumulated  as  to  the  beneficial  effects  of  electricity  applied  to  the 
stomach,  both  by  the  direct  and  the  percutaneous  methods,  yet  the 
modus  operandi  is  still  a  matter  of  great  doubt.    Thus,  what  is  true 

*  Stockton.  A  New  Gastric  Electrode.  N.  Y,  Medical  Record,  November 
9,  1889.  Clinical  Results  of  Gastric  Faradization.  Amer.  Jour.  Medical  Sciences, 
July,  1890. 

f  [Brock.     Therapeut.  Monatshefte,  June,  1895.— Ed.] 

X  Pepper.  A  Case  of  Scirrhus  of  the  Pylorus,  with  Remarks  on  the  Electrical 
Excitation  of  the  Stomach.     Philadelphia  Medical  Times,  May,  1871. 


ELECTRIZATION  OF  THE  STOMACH.  107 

of  electrical  therapeusis  in  other  parts  of  the  body  is  also  true  of  the 
stomach.  That  much  is  taken  for  granted  without  sufficient  proof 
has  recently  been  shown  by  Meltzer  in  a  most  admirable  paper.*  In 
a  series  of  unimpeachable  experiments  on  dogs,  cats,  and  rabbits, 
Meltzer  has  shown  that  the  mucous  membrane  of  the  stomach  and 
small  intestines  offer  an  almost  insurmountable  barrier  to  the  pas- 
sage of  the  f  aradic  current. 

Meltzer  maintains  that  there  is  no  positive  proof  of  the  generally 
accepted  assumptions  that  percutaneous  electrization  of  the  stomach 
and  intestiues  produces  a  contraction  of  these  viscera,  and  that 
stimulation  of  the  mucous  membrane  of  the  stomach  is  the  most 
direct  and  safest  way  to  effect  its  contraction.  In  his  experiments, 
for  the  details  of  which  I  would  refer  the  reader  to  his  paper, 
Meltzer  shows  that  not  even  all  parts  of  the  stomach  of  animals 
respond  to  direct  faradization,  and  that  the  response  is  greater  as 
we  approach  the  pylorus.  As  for  direct  faradization  of  the  stom- 
ach, even  with  the  strongest  currents,  his  experiments  prove  that 
although  contractions  may  be  obtained  in  some  parts  of  the  stomach 
when  both  electrodes  are  applied  on  the  outside  of  the  viscus,  yet 
there  is  absolutely  none  when  one  electrode  is  inside  and  the  other 
outside  of  the  viscus  or  on  the  shaved  skin  above  it.  The  same 
negative  results  were  obtained  when  the  stomach  was  filled  with  a 
saline  solution  and  the  electrode  submerged,  and  even  pressed 
against  the  mucous  membrane,  the  other  electrode  being  placed 
on  the  outer  surface  of  the  stomach  or  on  the  abdominal  wall. 
Meltzer  almost  demonstrates  that  in  the  percutaneous  methods  the 
contractions  are  obtained  with  the  abdominal  muscles,  but  none 
whatever  in  the  stomach  itself.  Similar  experimental  results  were 
obtained  by  Moritz.f 

As  E-iegel :{:  properly  urges,  these  results  on  small  animals  under 
anaesthesia  can  not  be  applied  directly  to  human  beings  with  gastric 
disorders  ;  hence  he  would  prefer  clinical  evidence  rather  than  de- 
pend upon  experimental  data  alone.     Yet  the  experiments  made  by 

*  [Meltzer.  An  Experimental  Study  of  Direct  and  Indirect  Faradization  of  the 
Digestive  Canal  in  Dogs,  Cats,  and  Rabbits.  New  York  Medical  Journal,  June  15, 
1895.J 

t  [Moritz.     Miinch.  med,  Wochenschr.,  1895,  No.  49.— Ed.] 

X  [Riegel,  loc.  cit.,  p.  806. — Ed.J 


108  DISEASES  OP  THE  STOMACH. 

Goldsclimidt*  on  normal  subjects,  and  also  on  two  patients  with 
dilatation  of  the  stomach  with  lessening  of  the  motor  functions, 
agree  entirely  with  the  negative  results  obtained  by  Meltzer. 

Concerning  the  effects  of  electricity  on  absorption  and  secretion 
there  is  still  much  doubt. 

The  conclusions  of  Goldschmidt  *  give  a  very  good  idea  of  the 
present  views  as  to  the  value  of  direct  electrization  of  the  stomach : 
1.  Direct  (i.  e.,  intragastric)  galvanization  is  an  excellent  means 
for  combating  gastric  neuroses ;  it  is  also  serviceable  in  organic  dis- 
orders. 2.  There  is  no  marked  difference  between  direct  galvan- 
ization and  faradization ;  and  yet  galvanization  (anode  in  stomach) 
is  preferable  in  painful  affections,  faradization  being  better  for 
functional  disturbances.  3.  The  actual  way  in  which  electricity 
acts  is  still  obscure.] 

At  this  place  I  might  also  speak  of  the  gymnastics  of  the  abdom- 
inal organs,  and  of  massage  and  the  hydriatio  treatment  of  the 
stmnach'^  but,  disregarding  the  simplest  measures,  like  rubbing 
with  cold  or  gradually  cooled  water,  compresses,  and  half  baths 
and  wet  packs,  with  or  without  douches,  the  household  remedies  of 
hydrotherapy,  as  it  were,  the  methodical  treatment,  especially  when 
combined  with  electric  baths,  requires  the  direction  of  a  specialist, 
and  apparatus  which  is  only  to  be  found  and  properly  used  in  hydro- 
therapeutic  establishments.  I  would  also  recommend  the  same  in 
regard  to  massage,  and,  whenever  it  is  possible,  it  ought  only  to  be 
done  by  properly  trained  persons. 

*  [Goldschmidt.     Deutsch.  Arch,  fur  klin.  Med.,  Bd.  Ivi,  Heft  3,  4.— Ed.] 


CHAPTEK   III. 

STEKOSES   AND    STEICTUEES    OF   THE    (ESOPHAGUS    AND    OF   THE    CAEDIA. 

DisEEGAEDiNG  tlie  obstructioDS  situated  higlier  up  in  tlie  moutli 
and  throat,  and  the  accidental  swallowing  of  foreign  bodies  (bones, 
etc.)  which  become  impacted  at  the  cardia,  and  relegating  them  to 
the  hands  of  the  surgeon,  we  find  that  the  oesophagus  and  the  en- 
trance to  the  stomach — the  mouth  or  cardia — ^may  be  obstructed  in 
various  ways,  and  the  swallowed  food  thus  more  or  less  impeded  in 
entering  the  stomach. 

Only  the  chronic  conditions  will  be  considered  here,  while  the 
acute  inflammatory  affections,  which  may  produce  a  temporary  ob- 
struction of  the  oesophagus,  such  as  catarrhal,  diphtheritic,  phleg- 
monous, pustular,  corrosive,  and  ulcerative  oesophagitis,  will  only  be 
discussed  in  so  far  as  their  consequences  may  result  in  a  permanent 
narrowing  of  the  lumen  of  the  oesophagus.  Therefore  the  con- 
ditions under  discussion  include  strictures  and  stenoses  due  to 
ciGatrices,  neojolasms,  diverticula  and  spastic  contractions  of  the 
(Esophagus. 

The  symptoms  to  which  these  conditions  give  rise  possess  a  great 
deal  in  common  in  spite  of  the  most  manifold  causes  which  may 
produce  them.  The  fundamental  feature  is  the  inability  to  convey 
the  food  which  has  been  swallowed  into  the  stomach,  and  from  this 
obstruction  to  the  introduction  of  food  the  other  complicating  phe- 
nomena are  developed. 

In  most  cases  the  passage  through  the  cardia  is  gradually  oc- 
cluded. In  the  beginning  there  are  times  when  absolutely  no  ob- 
struction to  swallowing  seems  to  exist ;  while  at  others  the  patients 
distinctly  feel  that  the  food  is  retarded  above  the  stomach,  "  that  it 
lies  like  lead  above  the  stomach,"  but  that  by  repeated  movements 

of  swallowing,  by  waiting,  and  drinking,  it  may  be  forced  past  the 

109 


110  DISEASES  OF  THE  STOMACH. 

narrowed  spot  into  tlie  viscus.  At  this  time  fluids  and  very  soft 
foods  do  not  usually  cause  any  difficulty,  but  the  obstruction  is  more 
marked  the  more  consistent  the  food  and  the  larger  the  morsels 
that  are  eaten ;  for  instance,  if  too  large  a  piece  of  meat  or  the 
like  be  accidentally  or  hurriedly  swallowed,  it  can  readily  cause  a 
transient  complete  closure  which  will  not  even  permit  fluids  to  pass. 
Later  on  the  intervals  grow  progressively  shorter  and  finally  disap- 
pear entirely,  while  the  necessity  of  taking  food  in  a  fluid  form 
becomes  greater,  the  choice  of  food  continually  more  limited. 
Then  a  new  symptom  appears  in  the  form  of  regurgitation 
of  the  food,  which  is  brought  up  unchanged  except  for  the  admix- 
ture of  mucus  or  saliva ;  for  in  the  same  degree  that  the  obstruction 
at  the  cardia  becomes  greater  and  more  marked,  the  masses  which 
are  swallowed  must  gather  more  and  more  above  the  opening,  so 
that  they  can  readily  return  undigested  and  only  mingled  with 
saliva  and  mucus,  should  the  lower  sections  of  the  oesophagus  be  the 
seat  of  peristaltic  contractions,  or  should  they  be  compressed  from 
without  by  coughing,  etc.  A  patient  of  mine  who  had  a  carcinoma 
in  the  lower  third  of  the  oesophagus  has  written  an  excellent  descrip- 
tion of  this  condition. 

The  food  which  has  been  eaten — especially  meat,  potatoes,  and  bread — 
seems  to  stick  above  the  stomach,  the  entrance  to  which  appears  to  be 
narrowed.  I  frequently  experience  a  sensation  going-  up  and  down  the 
oesophagus  as  if  gases  were  ascending  to  the  level  of  the  sternum  and  then 
descending.  Then  I  must  swallow  frequently,  for  I  have  the  sensation  as 
if  the  food  had  reached  a  mountain  which  it  can  not  pass.  This  lasts 
two  to  four  minutes.  At  times  a  peculiar  noise  can  be  heard.  Then  the 
food  seems  to  pass  on.  At  times  belching  affords  relief.  Usually  there 
are  cold  sweats  and  dyspnoea,  the  appetite  is  lost,  and  exhaustion  follows. 
Retching  and  vomiting  of  mucus  occur  about  four  times  weekly.  This 
affords  no  relief,  as  no  real  belching  follows.  Soft  articles  of  food,  such 
as  grated  potatoes  and  fat,  white  meats,  pass  through  without  trouble,  al- 
though this  is  perceptible.  After  every  meal,  and  at  other  times  as  well, 
I  belch  frequently,  although  this  affords  only  temporary  relief  to  the 
sense  of  fullness.  The  stools  are  normal.  The  tongue  is  rarely  tolerably 
clean,  but  is  usually  coated.  Although  my  general  condition  is  fair,  yet 
my  strength  is  much  lessened. 

A  further  result  is  seen  in  the  consecutive  dilatation  of  the 
oesophagus,  which  may  appear  the  more  readily  since  a  sHght  con- 
genital expansion  is  occasionally  found  in  it  close  to  the  entrance 
into  the  stomach,  forming  what  Luschka  calls  the  "  ante-stomach  " 


SYMPTOMS  OP  STENOSIS   OP   CARDIA.  HI 

(  Vormo-gen).  Yet  Yon  Ziemssen  and  Zenker  *  rightly  remarke(3 
that  this  dilatation  is  by  far  not  so  frequently  found  as  one  would 
infer  from  the  statements  in  the  text-books.  Of  course,  a  great 
deal  depends  on  what  is  understood  by  "  dilatation  "  ;  and  if  these 
authors  speak  of  a  case  of  ectasis  of  the  oesophagus  with  a  diameter 
of  5  centimetres  [2  inches]  in  the  widest  part  of  the  dilated  portion, 
I  can  oppose  thereto  what  I  found  in  two  out  of  three  autopsies  in 
cases  of  stricture  of  the  cardia,  in  which  the  widest  part  of  the 
oesophagus,  situated  5  centimetres  [2  inches]  above  the  cardia, 
measured  6*2  or  possibly  6  centimetres  [2|-  to  2f  inches],  while 
higher  .up  the  diameter  was  only  3  centimetres  [1-|-  inch].  I^either 
of  the  cases  impressed  one  in  any  way  as  marked  ectases  of  the 
oesophagus  from  the  mere  inspection  of  the  anatomical  preparations. 

Dilatation  helow  the  stricture  is  a  very  unusual  occurrence,  which 
I  encountered  some  time  ago  f  in  a  patient  who  had  a  carcinomatous 
stricture  14  centimetres  [5*6  inches]  below  the  introitus  oesophagi. 
Below  the  stricture  there  was  a  marked  dilatation  of  the  oesophagus, 
which  was  12  centimetres  [4:'8  inches]  in  its  transverse  diameter. 
The  muscular  fibres  and  the  mucous  membrane  in  this  dilated  area 
were  almost  entirely  gone ;  the  dilatation  and  the  cardia  were  continu- 
ous, without  any  constriction  between  them.  Probably  the  deficient 
contractility  of  the  lower  section  of  the  oesophagus  led  to  stag- 
nation of  the  food  above  the  cardia,  and  hence  produced  the  dila- 
tation. 

Thus,  as  far  as  the  space  will  permit,  the  ingesta  collect  in  the 
oesophagus  above  the  cardia  till  they  irritate  its  walls  to  such  an  ex- 
tent that  they  are  reflexly  expelled  by  the  pressure  due  to  the  strong 
efforts  at  coughing.  These  efforts  at  expulsion  and  vomiting,  fol- 
lowing at  first  only  after  eating,  may  finally  also  appear  between 
meals  without  food  having  been  taken  immediately  before.  At  first 
the  regurgitation  of  food  is  mostly  incomplete,  since  the  oesophageal 
contents  are  forced  up  but  a  short  distance  and  then  sink  down 
again  after  that  portion  which  has  in  the  meantime  become  fiuidi- 
fied  passes  by  the  stricture.     Later  on  this  takes  place  in  a  more 

*  Von  Ziemssen  und  Zenkei'.     Oesophaguskrankheiten,  in  Handbuch  der  Krank- 
heiten  des  chylopoetischen  Apparates,  i,  p.  33. 

f  Ewald.     Dilatation  der  Speiserohre.    Berl.  klin.  Wochenschr,,  1889,  No.  23. 


112  DISEASES  OF  THE  STOMACH. 

marked  degree,  and,  as  Brinton  *  says,  it  may  be  easily  understood 
that  since  the  oesophageal  contents  are  compressed  by  the  normal 
peristalsis  which  runs  from  above  downward,  a  central  core  must 
escape  above,  just  as  this  occurs  under  similar  circumstances  in  the 
centrally  perforated  piston  of  a  pump  or  syringe. 

The  expelled  masses  consist  of  the  unchanged  ingesta  mixed 
with  mucus  and  saliva,  in  which  chemical  examination  completely 
fails  to  show  the  products  of  gastric  digestion.  At  times  the  spe- 
cific tissues  of  a  neoplasm  may  be  recognized  under  the  microscope. 
Unless  specially  colored  fluids  (red  wine,  fruit  juices,  strongly  colored 
medicines,  etc.)  have  been  taken,  the  vomited  matter  usually  has  a 
grayish- white  or  yellowish-gray  color,  without  a  trace  of  bile.  I 
wish  to  call  particular  attention  to  this  last  point,  for  the  absence  of 
biliary  coloring  matters  may  be  of  the  utmost  importance  in  decid- 
ing whether  we  have  to  deal  with  oesophageal  or  gastric  contents — a 
decision  which  at  times  may  be  very  difficult.  Exceptionally  food 
which  has  been  eaten  at  a  previous  meal  is  brought  up,  while  none 
of  that  taken  last,  so  far  as  it  possesses  characteristic  constituents,  is 
to  be  found.  Since  this  is  not  a  rare  occurrence  in  diverticula  of 
the  oesophagus,  and  one  which  under  the  then  existing  circumstances 
can  be  readily  explained,  it  might  in  such  a  case  cause  the  diagnosis 
of  diverticulum  to  be  established  or  its  presence  to  be  suspected.  In 
this  connection  I  can  refer  to  autopsies  made  by  me  in  two  cases  of 
stenosis  of  the  cardia  with  dilatation,  but  without  the  formation  of 
any  diverticula,  in  which  the  condition  described  had  been  re- 
peatedly observed,  and  consequently  the  question  of  the  presence 
of  a  diverticulum  was  frequently  debated  during  Kfe,  but  in  which, 
as  I  have  said,  the  oesophagus  was  entirely  free  from  any  such  for- 
mation, Thns  this  condition  can  not  be  regarded  as  a  positive  diag- 
nostic factor  indicating  an  existing  diverticulum.  It  could  only 
come  into  play  in  case  of  partial  perviousness  of  the  stricture,  in 
which  certain  articles  of  food  could  pass  through  more  rapidly, 
while  others  would  be  detained  there  for  a  longer  time. 

At  all  events,  the  passage  of  food  through  such  stenoses,  espe- 
cially when  they  are  of  a  carcinomatous  nature,  is  not  infrequently 
very  variable  during  the  course  of  the  disease,  so  that  periods  of 

*  W.  Brinton.    Lectures  on  the  Diseases  of  the  Stomach.    London,  1864,  p.  10. 


TUBERCULOSIS   OP   CESOPHAGUS.  •  113 

greater  or  less  difficulty  in  swallowing  may  alternate.  This  is  dne 
to  the  varying  degrees  of  inflammatory  swelling  of  the  tissues  about 
the  neoplasm,  which  thus  produces  a  more  or  less  marked  stenosis  of 
the  lumen  of  the  oesophagus.  I  wish  also  to  call  attention  to  the 
fact  that  even  when  the  oesophagus  is  impassable  to  bougies,  suf- 
ficient soft  or  fluid  food  may  be  swallowed,  so  that  there  is  no  loss  of 
the  patient's  weight  for  a  considerable  period.  However,  after  a 
time  the  inevitable  results  of  the  impaired  nutrition  appear  and 
gvo^  pari  passu  with  the  increasing  constriction,  and  finally  lead 
to  a  marked  degree  of  emaciation  and  weakness.  The  abdomen 
sinks  in,  the  epigastric  and  hypochondriac  regions  being  specially 
retracted,  and  the  pulsation  of  the  aorta  can  be  very  plainly  felt 
through  the  walls ;  the  muscles  and  fat  waste  away  more  or  less ; 
the  skin  becomes  pale,  waxy,  or,  especially  in  the  face,  assumes  the 
specific  yellowish-green  color  of  the  cancerous  cachexia.  The  eyes 
are  sunken,  the  lips  thin,  the  nose  and  cheek  bones  become  pointed 
and  prominent.  The  tongue  usually  has  a  thick  white  coat,  and, 
despite  careful  cleansing  of  the  mouth,  a  fetid  odor  emanates  from 
it.  The  stools  are  small  and  tardy,  and  the  faeces  are  hard,  dry, 
and  scybalous ;  the  urine  is  scanty,  with  few  solid  constituents — in 
one  case  I  was  scarcely  able  to  find  a  trace  of  the  chlorides — and 
toward  the  end  of  life  now  and  then  contains  albumen.  Puffiness 
over  the  malleoli,  and  also  slight  cedema  of  the  legs,  usually  appear 
toward  the  end  of  the  disease.  To  be  sure,  the  picture  just  drawn  is 
very  essentially  modified  by  the  causative  factor  of  the  disease  and 
by  the  constitution  of  the  patient. 

Here  we  must  make  a  distinction  between  the  strictures  which 
are  due  to  neoplasms  from  those  which  have  been  caused  by  cica- 
trices after  tubercular,  syphilitic,  corrosive,  or  peptic  erosions  or 
ulcers  of  the  mucous  membrane  ;  for  the  course  and  the  influence 
of  treatment  in  the  latter  class  usually,  but  unfortunately  not  always, 
give  a  much  better  prognosis.  Life  is  least  of  all  endangered  in  the 
'spastic  strictures. 

Tuberculosis  of  the  oesophagus  needs  scarcely  be  considered,  since 
it  is  an  exceedingly  rare  condition.     Mazotti  *  has  reported  three 

*  Mazotti.     Delia  alterazioni  dell'    esofago  nella  Tuberculosi.    Rivista  clin., 
1885, 1. 


114  DISEASES  OP  THE  STOMACH. 

cases  of  oesophageal  tuberculosis  which  gave  no  symptoms  during 
life.  Mackenzie,*  in  his  large  work  on  The  Diseases  of  the  (Esopha- 
gus, reports  only  a  few  cases.f  But  even  in  these  rare  eases  the 
local  process  was  usually  accompanied  by  pulmonary  or  general 
tuberculosis ;  hence  there  is  no  primary  stenosis  of  the  oesophagus, 
and  consequently  no  special  treatment  is  indicated. 

Syphilitic  strictures  are  also  exceedingly  rare.  Jullien,:{:  in  his 
exhaustive  text-book,  reports  only  19  cases  from  1850  to  1884,  one 
of  which  is  the  case  published  by  Yirchow,*  in  which  there  was 
complete  atresia  of  the  posterior  nares  and  a  cicatricial  stenosis  of 
the  upper  part  of  the  oesophagus.  Lublinski  ||  has  added  two  cases ; 
one  of  these  was  a  man  29  years  of  age,  who,  without  presenting 
any  other  manifestation  of  syphilis,  had  a  stricture  at  the  level  of 
the  sixth  dorsal  vertebra ;  the  other  was  a  man  54  years  old,  who 
had  a  gumma  of  the  tongue  and  a  stenosis  at  the  level  of  the  fifth 
dorsal  vertebra.  Both  cases  were  cured  with  potassic  iodide.  Such 
specific  stenoses  or  strictures  may  be  caused  either  by  submucous 
gumraata  or  by  ulceration  with  consecutive  cicatrization,  [j^eu- 
mann  ^  reports  two  additional  cases  of  his  own,  and  gives  complete 
bibliography  of  all  reported  cases  of  syphilitic  disease  of  the  oesopha- 
gus.] 

Cicatricial  Strictures  may  be  divided  into  two  classes.  The  first 
include  those  which  are  the  result  of  direct  corrosion  from  swallow- 
ing caustic  fluids  or  substances,  inflammatory  processes,  trauma, 
burns,  and  diphtheria.  In  such  cases  the  etiology  may  easily  be  es- 
tablished by  the  history,  unless  the  facts  are  purposely  concealed  or 
the  injuries  have  been  inflicted  by  the  patient  during  an  attack  of 
insanity  or  intoxication.  Eokitanski  and  Yirchow  have  long  ago 
established  the  fact  that,  after  swallowing  corrosive  fluids,  the  favor- 
ite sites  of  injury  are  the  beginning  of  the  upper  and  the  lower 

*  Mackenzie.     Krankheiten  das  Kehlkopfs.     Berlin,  1884. 

f  [Additional  cases  have  been  reported  by  Meyerhof.  Ueber  Krebs  und  Tuber- 
kulose  des  Speiserohre.  Inaug.  Dissert.  Giessen,  1894. — Hasselmann.  Ueber  Tu- 
berkulose  der  Oesophagus.    Inaug.  Dissert.     Munich,  1895. — Eu.] 

X  L.  JuUien.    Maladies  veneriennes.     Paris,  1886. 

*  Virehow's  Archiv,  Bd.  xv,  p.  207. 

II  Lut)linski.  Die  Syphilitischen  Stenosen  des  Oesophagus.  Berl.  klin.  Wochen- 
schr.,  1883,  Nos.  33  and  34. 

^  [Neumann.     Syphilis,  Nothnagel's  Encyclopedia,  Bd.  xxiii,  p.  346, 1896. — Ed.] 


PEPTIC   ULCERS   OF   CESOPHAGUS. 


115 


thirds  of  the  oesophagus ;  hence  the 
resulting  cicatrices  are  typically  found 
at  these  situations,  and  not  infrequently 
at  the  same  time  at  both  places.  This 
is  easily  understood,  since  the  investi- 
gations of  Kronecker  and  Meltzer  have 
shown  that  the  swallowed  mass  re- 
mains immediately  above  the  cardia 
after  having  been  hurried  through  the 
oesoj)hagus. 

Such  strictures  may  occur  at  any 
age.  Yon  Hacker  *  has  described 
cases  in  infants  18  and  21  months  old. 
]S^ot  long  ago,  at  the  Augusta  Hospital, 
I  had  a  three-year-old  child  with  two 
absolutely  impassable  strictures,  which 
were  caused  by  the  nurse's  careless 
administration  of  a  strong  soda  lye 
(Fig.  22). 

The  second  class  includes  those  pro- 
duced hj peptic  ulcers,  ulcus  oesophagi 
ex  digestione.  These  cases  are  rare, 
but  their  occurrence  has  been  firmly 
established  by  the  observations  of  Eras, 
Quincke,  Chiari,  Berrez,  Sabel,  and 
others.f  In  these  cases  it  is  believed 
that  the  lower  portion  of  the  oesopha- 
gus is   corroded  by  the  regurgitation 


*  Von    Hacker.       Speiserohreverengungen, 
Vienna,  1887. 

f  Eras.  Die  Anatoraischen  Canalizations- 
st5rungen  der  Speiserohre.  Leipzig,  1866. — 
H.  Quincke.  Ulcus  oesophagi  ex  digestione. 
Deutsch.  Arch,  fiir  klin.  Med.  Bd.  xxiv,  p.  72. — 
Chiari.  Prager  med.  Wochenschr.,  1884.  p.  278. 
— Berrez.  De  I'ulcere  simple  de  I'oesophage.  These  de  Paris.  1888. — Sabel.  Beitrage 
zur  Lehre  vora  peptischen  Geschwiirs  des  Oesophagus.  Dissert.  Gottingen,  1891. 
[An  additional  case  is  that  reported  by  Guiteras  (International  Medical  Magazine, 
November,  1894).     One  peptic  ulcer  was  situated  4^  inches  below  the  cricoid  carti- 


FiG.  22. — Two  almost  impassable  ci- 
catricial strictures  in  oesophagus 
of  child. 


116  DISEASES  OP  THE  STOMACH. 

of  acid  gastric  juice,  and  tliat  there  is  subsequent  cicatrization  of 
the  ulcers  wliicli  are  thus  produced.  In  1892  *  I  reported  such  a 
case,  which  occurred  in  a  girl  19  years  of  age,  in  whom  the  obstruc- 
tion of  the  oesophagus  was  so  complete  that  gastrostomy  had  to  be 
performed  to  save  her  hfe.  A  careful  consideration  of  all  the 
symptoms  will  enable  one  to  diiferentiate  these  cases  from  a  possible 
neoplasm,  stenosis  from  other  causes,  or  a  diverticulum.  A  neoplasm 
may  be  excluded  by  the  usual  youthful  age  of  the  patient,  the  ab- 
sence of  glandular  swellings,  cancerous  cachexia,  as  well  as  by  the 
fact  that  painful  deglutition  occurred  at  the  beginning  of  the  trouble, 
but  which  later  was  less  marked,  or  even  disappeared ;  in  neoplasms 
the  reverse  is  usually  true.  The  history  of  the  case  and  the  site  of 
the  stenosis  will  enable  one  to  differentiate  these  cases  from  stric- 
tures after  corrosion  or  diverticula ;  the  latter  occur  only  in  the 
upper  third  of  the  oesophagus. 

Spastic  Strictures — i.  e.,  the  spasmodic  contraction  of  the  muscular 
fibers  of  the  oesophagus  during  deglutition — are  alwa3^s  the  result  of 
a  necrosis  or  of  a  reflex,  consequently  of  a  purely  functional  nature, 
and  can  in  general  be  easily  distinguished  from  the  firm  closure  of  the 
cardia  by  the  following  points  :  The  contractions  are  frequently  in- 
termittent, sometimes  being  entirely  absent,  and  at  other  times  ap- 
pearing only  feebly — ^i.  e.,  with  complete  integrity  of  the  power  of 
deglutition.  They  occur  in  paroxysms  due  to  mental  disturbances, 
exhausting  attacks, f  neuralgias,:]:  palpitation  of  the  heart,  etc.  Direct 
or  more  remote  irritating  factors,  such  as  oesophagitis  and  gastritis, 
even  gastric  carcinoma,  metritis,  pregnancy,  and  irritation  due  to 
worms,  can  also  produce  spasm  of  the  oesophagus.     They  occur  in 

lage ;  two  large  ulcers  which  had  perforated  were  opposite  the  bifurcation  of  the 
trachea;  the  oesophagus  was  ulcerated  to  the  cardia.  The  patient  was  a  woman  44 
years  old,  who  ruminated  ;  this  will  explain  the  lesion. — Ed.] 

*  Ewald.     Zeitschr.  fiir  klin.  Med.,  Bd.  xx,  Hefte  4-6. 

■f  Carron.  Observation  sur  une  suspension  de  la  deglutition  pendant  plus  de 
deux  jours  produit  par  un  eraetique  violent  ehez  un  homme  atteint  d'une  dyspepsie 
rhumatique.  J.  gener.  de  med.,  chirurg.  et  pharm.  Paris,  1811,  pp.  58-62.  A  re- 
markable case,  entitled  Spasmodic  Inability  of  Deglutition  caused  by  Mercurial 
Unction,  is  reported  in  the  Med.  Obs.  Soc.  Phys.,  London,  1784,  which  I  was  unable 
to  procure. 

X  Coin  reports  A  Case  of  Spasm  of  the  (Esophagus  and  Air-passages  from  Dorso- 
intereostal  Neuralgia.  This  was  mistaken  for  an  organic  stricture.  Charleston 
Med.  J.  Eev.,  1851,  pp.  199-205. 


SPASTIC  STRICTURES  OP  (ESOPHAGUS.  117 

neuropathic  persons  suffering  with  nervousness,  neurasthenia,  and 
hysteria,  and  on  observation  they  can  be  recognized  as  specially 
well-marked  features  of  a  general  nervous  disease.  Furthermore, 
such  obstructions  can  be  overcome  by  a  tldck  sound,  either  immedi- 
ately or  after  it  has  been  kept  in  the  oesophagus  for  a  short  time. 
This  procedure  will  also  succeed  under  chloroform.  ISTaturally,  this 
could  not  be  done  where  the  stricture  is  organic.  I  purposely  say 
a  large  sound,  since  the  spasmodic  contractions  can  be  overcome 
more  readily  than  with  thin  instruments. 

It  is  well  known  that  spastic  strictures  may  appear  throughout 
the  whole  length  of  the  oesophagus,  and  at  times  may  become  so 
marked  as  to  simulate  the  symptoms  of  hydrophobia.*  They  may 
exist  for  months  and  even  years  without  specially  influencing  the 
nutrition  of  the  patient ;  thus  we  meet  with  well-fed  ladies  who  say 
that  they  "  are  unable  to  force  down  a  morsel."  Yet  such  spasms 
may  lead  to  the  most  severe  disturbances  of  nutrition  and  may  even 
result  in  death.f  The  seat  of  the  spasm  is  shown  by  the  distance  to 
which  the  sound  can  be  introduced  until  it  reaches  the  constricted 
spot,  unless,  as  I  saw  in  one  case,  the  sound  invariably  passes  into 
the  stomach  with  ease,  and  the  spasm  appears  only  on  eating — i.  e., 
swallowing  solid  or  fluid  foods,  and  then  not  at  once,  but  only  later. 
The  patients  are  frequently  able  to  overcome  the  spasm  by  various 
manipulations,  as  can  be  seen  in  the  following  history  of  such  a 
case :  % 

Miss  M.,  from  New  York,  August  15,  1885.  Age  thirty-three.  Well 
nourished  ;  appetite  good  ;  bowels  regular.  Asserts  that,  on  swallowing, 
the  food,  both  liquid  and  solid,  lies  above  the  stomach.  She  is  able  to 
take  a  small  plate  of  soup  and  a  corresponding  quantity  of  other  nourish- 
ment, but  then  she  must  make  extra  exertions  to  force  the  mass  down  into 
the  stomach. 

Stomach  in  the  normal  position,  somewhat  distended.  Normal  on 
percussion  and  palpation.  Patient  eats  two  cakes  and  drinks  a  glass  of 
water,  but  the  murmurs  of  deglutition  could  not  be  heard.     After  repeated 

*  J.  Barnes.  A  Singular  Case  of  Spasmodic  Disease  simulating  Hydrophobia. 
Amer.  Medical  Record,  1822,  pp.  650-652. 

f  H,  Power.  On  a  Case  of  Spasmodic  Stricture  of  the  CEsophagus  terminating 
fatally.  The  Lancet,  1866,  i,  No.  10.  The  patient,  refusing  an  operation,  died  of 
inanition.     Nothing  found  at  the  autopsy. 

X  This  case  has  since  been  reported  in  full  by  Meltzer,  Berlin  klin.  Wochenschr,, 
1888,  No.  3. 


lis  DISEASES   OF   THE   STOMACH. 

deep  inspirations  and  simultaneous  efforts  at  swallowing  she  forces  air 
into  the  gullet,  and  then  at  the  same  time  we  can  hear  a  very  pronounced 
and  loud  sound  as  if  something  were  being  squirted  through  (Durch- 
spritzgerdusch).  The  stomach  tube  is  arrested  at  the  cardia ;  the  English 
sound  enters  the  stomach  after  overcoming  a  certain  resistance. 

In  this  case,  consequently,  in  which  there  were  no  manifest 
hysterical  or  neuropathic  factors  to  account  for  the  spasm,  it  could 
be  overcome,  and  the  general  nutrition  of  the  patient  was  corre- 
spondingly but  slightly  influenced.  ^Nevertheless,  her  condition 
was  extremely  painful  and  unpleasant,  for  at  her  meals  she  was 
forced  to  leave  the  table  as  soon  as  she  had  taken  a  couple  of  mor- 
sels, in  order  to  perform  her  "  swallowing  gymnastics,"  and  she  was 
thus  naturally  debarred  from  all  kinds  of  society  except  that  of  her 
most  intimate  friends.  In  this  case  there  was  evidently  spasm  of 
the  cardia,  due  to  its  hypersensibility,  a  condition  of  which  I  shall 
speak  again  under  the  neuroses  of  the  stomach. 

I  have  since  seen  many  cases  of  spastic  stricture  of  the  oesopha- 
gus, and  even  in  men ;  these  patients  always  have  marked  neuro- 
pathic tenderness,  but  the  spasm  of  the  oesophagus  is  the  most 
prominent  symptom,  and  is  hence  the  chief  cause  of  complaint. 

The  neoplasms  which  lead  to  consi/piGtion  of  the  (Esophagus  re- 
solve themselves  into  those  which  exert  pressure  from  without,  and 
those  which  are  situated  in  the  tissues  of  the  digestive  tract  and 
which  grow  from  its  wall  into  the  lumen. 

Among  the  former  class  we  find  tumors,  abscesses,  and  solid 
swellings  of  a  carcinomatous,  sarcomatous,  or  fibrous  nature,  which 
develop  in  the  tissues  of  the  mediastinum  or  retroperitonasum ;  or 
they  may  be  glands  which  have  undergone  carcinomatous  or  scrofu- 
lous degeneration ;  or  they  may  be  osseous  or  periosteal  tumors 
growing  from  the  vertebral  column ;  or,  finally,  aneurisms  of  the 
large  arteries.  We  may  also  include  the  cases  of  dysphagia  which 
are  caused  by  the  swelling,  suppuration,  or  calcification  of  the  glands 
at  the  bifurcation  of  the  trachea  and  the  small  bunch  of  glands 
which  lies  above  the  foramen  oesophageum  of  the  diaphragm. 
Thus  a  case  has  been  reported  by  Cahn,*  in  which  a  large  glandular 

*  Quoted  by  Korner.  Ueber  Dysphagie  bei  Erkrankungen  der  Bronchialdriisen. 
Deutsch.  Arch,  fur  klin.  Med.,  Bd.  xxxvii,  p.  281. 


DIVERTICULA   OF   (ESOPHAGUS,  119 

mass  surrounded  the  bifurcation  of  the  tracliea  and  was  adherent  to 
the  outer  wall  of  the  oesophagus  without  causing  any  changes  in  the 
inner  coats.  These  cases  are  usually  tubercular  or  scrofulous  ;  much 
less  frequently  primary  carcinomata,  or,  at  most,  metastases.  In 
some  cases  perforations  into  the  oesophagus,  and  even  communica- 
tion between  bronchus  and  oesophagus,  have  occurred.* 

I  shall  here  refer  only  casually  to  diverticula  of  the  msopJiagus  / 
these  must  be  carefully  distinguished  from  the  above-mentioned 
saccular  dilatations,  which  are  formed  after  stenoses  have  existed 
for  a  long  time ;  for  the  former  are  as  rare  as  the  latter  are  com- 
mon. This  is  especially  true  of  the  so-called  traction  diverticula — 
i.  e.,  partial,  funnellike  bulgings  of  the  wall  of  the  oesophagus,  which 
are  produced  thus :  A  circumscribed  area  of  the  outer  wall  of  the 
oesophagus  becomes  adherent  to  some  adjacent  organ,  usually  a 
bronchial  gland  or  the  mediastinum,  and  is  drawn  outward  by  the 
retraction  of .  the  latter.  [Their  usual  site  is  on  the  anterior  wall 
near  the  bifurcation  of  the  trachea.]  They  are  pathological  finds 
which  have  no  practical  significance.  ^\q  j^resaxire  diverticula  are 
much  more  important ;  they  are  sacculated  230uches  which  also  in- 
volve only  a  portion  of  the  circumference  of  the  oesophagus,  usually 
its  posterior  wall,  the  origin  of  which  is  due  to  the  pressure  of  food 
against  some  spot  which  is  naturally  weak,  or  which  has  lost  its 
resistance  as  the  result  of  some  previous  injury.  It  is  evident  that 
such  diverticula  when  distended  with  food  or  saliva  will  displace 
the  oesophagus,  and  may  compress  it  to  such  a  degree  that  all  the 
food  will  enter  the  diverticulum ;  the  obstruction  will  be  rendered 
worse  by  the  patient's  efforts  to  overcome  it  by  taking  more  food. 
Pressure  diverticula  are  always  found  in  the  upper  third  of  the 
oesophagus  [usually  at  its  junction  with  the  pharynx]  ;  when  they 
are  large  they  form  a  swelling  in  the  neck,  the  size  of  which  is 
variable.  A  sound  can  only  be  passed  through  the  oesophagus 
when  the  sac  is  empty ;  otherwise,  as  shown  above,  the  sound  will 
enter  the  sac.  As  they  are  accessible  for  surgical  interference, 
many  successful  operations  have  already  been  reported,  f 

*  Heddaeus.     Dysphagie  durch  Schwellung  der  Bronchialdriisen.     Berl,  klin. 
Wochenschr.,  1889,  No.  36. 

t  [The  most  recent  literature  on  this  subject  includes :  Klemperer.     Ein  Fall 


120  DISEASES  OP  THE  STOMACH. 

The  stenosing  neoplasms  of  the  oesophagus  are  carcinomatous  in 
the  great  majority  of  cases  and  are  situated  in  its  lower  half  or  two 
thirds.  Although  benign  growths,  such  as  myomata,  papillomata, 
fibromata,  adenomata,  and  cysts  in  the  walls  of  the  oesophagus,  have 
been  described,*  yet  they  are  very  rare  and  have  never  given  rise  to 
any  stenotic  symptoms.  The  favorite  site  of  oesophageal  cancer  is 
at  the  level  of  the  junction  of  the  fourth  and  fifth  dorsal  vertebrge 
— i.  e.,  8  centimetres  [3-2  inches]  below  the  introitus  oesophagi,  or 
23  centimetres  [9*2  inches]  from  the  incisor  teeth ;  somewhat  less 
frequently  they  are  just  above  the  cardia.f  The  reason  for  this 
is  that  both  of  these  places  are  subject  to  pressure  during  deglu- 
tition, the  former  because  it  is  at  this  point  that  the  left  bronchus 
crosses  the  oesophagus,  and  hence,  in  swallowing,  the  wall  of  the 
oesophagus  is  compressed  between  the  bolus  of  food  and  the 
bronchus;  the  latter  because,  as  already  explained,  the  masses  of 
food  are  arrested  at  the  cardia. 

It  is  far  beyond  my  province  to  enter  into  a  detailed  description 
of  all  these  various  diseases  of  the  oesophagus.  My  only  object  in 
presenting  them  was  to  recall  in  how  many  different  ways  the 
passage  of  food  to  the  stomach  may  be  interfered  with.  I  wish 
now  to  discuss  especially  the  processes  which  may  involve  the 
cardia,  but  which  nevertheless  really  occur  in  the  lower  portion  of 
the  oesophagus. 

Constricting  neoplasms  of  the  cardia  are  always  of  a  carcinoma- 
tous nature,  and  are  very  rarely  indeed  limited  exclusively  to  the 
orifice  of  the  stomach.     As  a  rule,  they  involve  the  cardia  from 

von  Pulsiondivertikel  des  Oesophagus.  Deutsch.  med.  Wochenschr.,  1894,  No.  30. 
Vereinsbeilage,  p.  65. — Korner.  Tractionsdivertikel  des  Oesophagus.  Inaug.  Dissert., 
Berlin,  1894. — EoUeston.  Traction  Diverticulum  of  CEsophagus.  Transact,  Lon- 
don Patholog.  Soc,  1895,  vol.  xlvi,  p.  47. — Kelling.  Zur  Diagnose  des  tiefsitzenden 
Speiserohredivertikels.  Miinch.  med.  Wochenschr.,  1894,  No.  47. — Also  Rosen- 
heim. Krankheiten  der  Speiserohre  und  des  Magens.  2te  Auflage,  1896,  chapter 
vi. — Ed.] 

*  Korner,  Ueber  die  nicht  carcinomatosen  Geschwillste  des  Oesophagus,  Ber- 
lin, 1884. 

f  [Voigt  (Ueber  Krebs  der  Speiserohre,  Inaug.  Dissert.,  Tubingen,  1894)  an- 
alyzed 72  cases  of  oesophageal  cancer  which  were  treated  at  the  Tiibingen  Clinic 
from  1871  to  1893.  It  occurred  most  frequently  in  the  lower  third  of  the  oesopha- 
gus— i.e.,  in  41  cases,  17  were  in  the  middle  third  and  4  in  the  upper  third. 
Metastases  occurred  in  9  cases.  In  3  there  was  perforation  into  the  left  bronchus 
and  trachea, — Ed.] 


CANCER   OF   CARDIA.  121 

above — tlie  lower  section  of  the  cesophagiis ;  or  less  freqiieiitly  fr^jm 
below — the  cardiac  portion  of  the  stomach. 

itokitanski  *  states  that  a  special  characteristic  of  cancer  c-i  the 
cardia  is  that  it  always  has  the  tendency  to  in  vol  re  the  oe=opha.gTLs, 
thus  contrasting  with  cancer  of  the  pylorus.  As  C'jr ''iel  ro  this 
assertion,  Brinton  f  cites  two  eases  of  sharply  locahzed  cancer  jf  :he 
cardia,  and  in  consideration  of  the  rarer  appearance,  on  iLr  vr^ile, 
of  malignant  growths  in  the  region  of  the  cari'lia,  he  ■  e'ieTes  that 
both  cancers  of  the  pylorus  and  of  the  cariiia  appear  '.:•:  .^iz-ed  with 
about  equal  frequency — ^that  is,  one  case  to  fifteen  in  which  it 
spreads.  Disregarding  my  own  personal  experience.  ~h:'h.  hy  the 
way,  agrees  entirely  with  Hokitanski's  views,  I  can  nni  la:  ie~ 
recorded  cases  of  isolated  cancer  of  the  cardia — two  cases  of  epi- 
thehal  cancer  of  the  size  of  an  egg,  de-^jrihed  Ijv  Han^jt,  :J:  -^vhich 
were  limited  exactly  to  the  cardia — and  aiio  tnr'Ciagh  the  l::n]:ces.3 
of  Prof.  Virchow,  I  saw  only  one  more  case  in  the  splendid  c chec- 
tion  of  our  [Berlin]  pathological  institute,  of  which  I  a:  leiia  a 
drawing  made  by  myself  (Tig.  23).  Should  we  wish  to  re-  : d  the 
neoplasms  which  strictly  involve  only  the  circular  muscnlar  ring  of 
the  cardia  as  localized  cancers,  we  can  easily  see  that  the  tendencv 
for  them  to  spread  has  already  been  provided  for  in  the  anat  nncai 
arrangement ;  for  the  muscnlar  layer,  as  is  well  known,  is  made  up 
of  semicircular  and  crossing  fibers  which  spread  from  the  cardiac  to 
the  fundal  zone  of  the  stomach. 

As  a  rule,  the  cause  of  these  tnmrjrs  is  not  to  he  disc  covered,  and 
the  hereditary  factor  is  far  oftener  absent  than  present.  I  shall 
again  treat  of  this  subject — heredity — in  the  general  discussion  oi 
carcinoma  of  the  stomach.  I  must  not  forget  to  mention  that  two 
of  my  patients  positively  ascribed  their  trouble  to  tratmiatisms. 
One  of  them,  a  lawyer,  traced  it  to  a  fall  in  which  he  hurt  his  chest : 
and  the  other,  a  farmer,  while  at  work  in  the  field,  suddenly  experi- 
enced a  sharp  pain  within  his  chest,  and  since  then  he  claims  that 
the  disease  developed.     In  both  there  was  cancer  of  the  cardia.     I 


*  RokitanskL    Handbuch  der  speciellen  pathologisehen  Anatomie.    Bd.  ii.  5.  205. 
f  Brinton.    Lectures  on  the  Diseases  of  the  Stomach.    Second  edition.  London, 
1864.  p.  227. 

$  Hanot.    Arch,  gener,  de  Med.,  October,  1881. 


122 


DISEASES  OF  THE  STOMACH. 


Fig.  23. — Localized  cancer  of  cardiac  orifice  of  stomach.     (From  Berlin  Pathological 
Institute.)    a,  oesophagus;  b,  localized  cancer  of  cardia  ;  c,  cavity  of  stomach. 

scarcely  need  say  that  siicli  statements  can  only  be  accepted  with  the 
greatest  caution.  The  well-known  necessity  of  man,  especially  a 
sick  man,  of  finding  a  cause,  frequently  leads  him  to  confound  the 
post  hoc  or  the  simul  cum  with  the  propter  hoc.  But  since  it  has 
been  proved  that  traumatisms  may  give  rise  to  carcinomata,  it  ap- 
pears to  me  that  this,  to  which  as  far  as  I  know  no  attention  has 
been  paid,  is  worth  mentioning. 


CANCER  OP  CARDIA.  123 

The  loss  of  the  patient's  strength  is  not  entirely  due  to  the  diffi- 
culty of  taking  food ;  for  F.  Miiller  and  Klemperer  have  shown  in 
all  patients  with  cancer,  and  Gaertig,*  in  cases  of  oesophageal  carci- 
noma in  particular,  that  the  nitrogenous  equilibrium — ^to  say  nothing 
of  any  gain  in  the  bodily  albumin — can  not  be  maintained  even 
when  the  greatest  possible  amount  of  albuminous  food  is  taken  ;  on 
the  contrary,  there  is  a  continual  loss  in  the  bodily  proteids.  This 
affords  a  scientific  explanation  of  the  steadily  increasing  cachexia  of 
these  unfortunate  persons. 

However,  the  general  bodily  condition  does  not  always  stand  in 
a  direct  relation  to  the  patency  of  the  cardia.  I  have  frequently 
seen  cases  in  which  the  stenosis  was  very  great,  yet  the  appearance 
and  strength  of  the  patient  was  quite  good,  even  if  they  said  that 
they  were  losing  ground.  On  the  other  hand,  the  general  cachexia 
due  to  the  constitutional  intoxication  may  be  very  great,  in  spite  of 
the  fact  that  the  stenosis  of  the  cardia  is  not  at  all  great.  It  is  a 
peculiarity  of  cardiac  cancers  that  the  general  symptoms,  such  as 
metastases,  enlarged  glands,  etc.,  are  relatively  sHght. 

I  would  direct  especial  attention  to  the  fact  that  adenopathies, 
which  are  usually  so  constantly  found  in  cancers  elsewhere,  are  by 
no  means  so  common  in  oesophageal  cancers.  They  are  absent  in 
the  majority  of  the  cases.  The  situation  in  which  they  ought  to  be 
found  are  the  left  axilla  and  supra-  and  infra-clavicular  regions. 
For  a  long  time  I  have  directed  my  attention  to  this  point,  and 
have  collected  170  cases  of  gastric  and  about  60  of  oesophageal 
cancers,  which  I  have  seen  in  my  own  practice  and  in  consultation. 
Small  glands,  up  to  the  size  of  a  bean,  have  no  diagnostic  signifi- 
cance, since  Dietrich's  f  careful  researches  have  shown  that  in 
healthy  persons  the  cervical  glands  are  enlarged  to  the  size  of  a  pea 
or  bean  in  Y4-7  per  cent,  the  axillary  in  68'9  per  cent,  the  cubital 
in  81-7  per  cent,  the  inguinal  in  92  per  cent.  Enlarged  peripheral 
glands  are  therefore  of  no  significance  unless  their  size  is  that 
of  a  hazelnut,  or  greater. 


*  H.  Gaertig.  Untersuchungen  iiber  den  Stoffwechsel  in  einem  Fall  von  Carci- 
noma Oesophagi.     Inaug.  Dissert.,  Berlin,  1890. 

f  Dietrich.  Die  Palpation  der  Lymphdriisen.  Erlanger  Sitzungsberieht,  July 
19,  1886. 


124  DISEASES  OP  THE  STOMACH. 

Among  the  least  frequent  of  the  common  symptoms  appearing 
in  the  course  of  the  disease  are  local  or  more  diffuse  pains.  True 
cardialgia — i.  e.,  marked  cramplike  pain,  with  a  definite  localization 
in  the  epigastric  region — does  not  occur  ;  and  thus,  too,  the  severe 
radiating  pains  which  so  often  accompany  carcinomatous  or  ulcera- 
tive processes  of  the  stomach  are  almost  always  absent.  Should 
they  be  present,  they  occasion  the  suspicion  that  the  process  is  not 
limited  to  the  cardia.  Most  frequently  the  patients  complain  of  a 
slight  burning  or  boring  pain,  or  only  of  a  feeling  of  pressure  in 
the  region  of  the  ensiform  cartilage.  At  times,  and  rather  in  the 
minority  of  cases,  this  may  be  increased  by  pressure  from  without 
on  the  ensiform  cartilage.  As  a  rule,  swallowing  causes  either  no 
special  increase  of  the  pain  or  none  at  all.  In  one  of  my  cases,  in 
which  the  carcinomatous  neoplasm  had  invaded  the  retro -peritoneal 
tissues,  the  patient  complained  of  pain  in  the  lumbar  region.  In 
many  cases  pain  is  entirely  absent. 

Exploration  with  the  oesophageal  bougie  is  absolutely  essential  in 
the  diagnosis  of  all  cases  of  stenosis  of  the  oesophagus  or  cardia. 
The  distance  to  the  cardia  from  the  incisor  teeth  naturally  varies 
with  the  height  of  the  individual.  The  average  figure  is  estimated 
to  be  40  centimetres  [16  inches],  of  which  15  centimetres  [6  inches] 
include  the  distance  from  the  incisors  to  the  commencement  of  the 
oesophagus,  5  centimetres  [2  inches]  belong  to  its  cervical,  lY  centi- 
metres [6f  inches]  to  its  thoracic,  and  3  centimetres  [1-^  inches]  to 
its  abdominal  portion.  I  have  repeatedly  found  much  greater 
measurements,  as  high  as  46  centimetres  [18f  inches]  m  toto.  We 
need  also  not  be  surprised  if  the  results  of  different  examinations  on 
the  same  patient  differ  1  or  2  centimetres  [f  to  f  inch]  ;  for  the 
sounds  are  very  apt  to  yield  and  bend  over  when  an  obstruction 
is  encountered,  and  thus  the  distance  to  which  they  have  been  in- 
troduced may  not  be  always  the  same. 

[Eecently,  Rosenheim  *  has  again  directed  attention  to  the  value  of 
the  oesophagoscope  in  the  diagnosis  of  all  affections  of  the  oesophagus, 
and  has  devised  new  instruments  for  this  purpose.  He  claims  that 
with  suitable  instruments  the  procedure  is  both  readily  learned,  and 

*  [Full  details  of  the  method  and  instruments  are  given  in  Rosenheim,  loc.  cit., 
pp.  99-112.— Ed. J. 


SOUNDING  OF   CESOPHAGUS.  125 

that  after  cocainization  the  oesophagus  may  easily  be  inspected  to 
the  cardia.  The  method  is  of  great  value  in  differential  diagnosis. 
Karstein's  autoscope  has  also  been  used  for  this  purpose.*] 

At  this  place  I  shall  introduce  a  few  practical  points  about  the 
sounding  of  the  (Esojphagus. 

For  sounding  the  oesophagus  we  must  use  either  the  oesophageal 
sponge  probang,  rigid  sounds,  or  the  tube.  The  first  consists  of  a 
small  sponge  about  the  size  of  a  hazelnut,  fastened  to  a  straight  or 
slightly  curved  piece  of  whalebone.  With  this,  if  it  be  long  enough 
— althouojh,  as  a  rule,  the  instrument-makers  make  them  much  too 
short — the  oesophagus  is  swept  out,  as  it  were,  the  presence  of  any 
obstruction  established,  and  possibly  shreds  of  tissue  caught  in  the 
meshes  of  the  sponge  and  brought  up  for  examination.  The  objec- 
tion to  the  instrument  is,  that  in  patients  who  have  a  narrow  en- 
trance to  the  oesophagus,  or  in  whom  there  is  marked  irritability  of 
the  constrictors,  considerable  force  is  needed  both  to  introduce  and 
to  remove  it  from  the  oesophagus,  for  at  times  it  is  caught  so  tightly 
immediately  at  the  entrance  (or,  in  the  other  sense,  the  exit)  of  the 
oesophagus,  or  at  a  certain  spot  behind  the  larynx,f  that  an  inex- 
perienced person  could  be  led  thereby  to  assume  an  abnormal  ob- 
struction. It  stands  to  reason  that  the  sponge  is  not  to  be  dry,  but 
that  it  must  be  moistened  and  always  thoroughly  cleansed  and  dis- 
infected before  it  is  used.  I  have  already  given  the  necessary 
information  concerning  the  technique  of  this  manipulation  on 
page  10, 

The  best  oesophageal  sounds  are  made  of  prepared  catgut.  They 
must  be  flexible,  and  are  either  bluntly  pointed  or  provided  with  a 
tapering  knobbed  extremity.  As  advantageous  as  the  latter  seems 
to  be  in  order  to  work  its  way  through  a  stenosed  or  constricted 
spot,  just  so  undesirable  do  these  sounds  prove,  for  the  thinned  por- 
tion above  the  knob  is  soon  bent  on  repeated  use,  I  never  employ 
sounds  which  contain  a  wire  or  which  consist  only  of  whalebone. 


*  [E.  Meyer.  Ueber  Autoskopie  unci  Oesophagoskopie.  Allgemeine  med.  Cen- 
tralzeitung.  1895,  No.  100.— Ed.] 

\  Waldeyer.  Beitrage  zur  normalen  nnd  vergleichenden  Anatomie  des  Pharynx 
mit  besonderer  Beziehung  auf  den  Schlirp-weg.  Sitzungsb.  d,  Akad.  d.  Wissensch. 
zu  Berlin,  Physik.-math.  Klasse,  Februar  25,  1886. 


126  DISEASES  OP  THE  STOMACH. 

because  they  are  too  liard,  or  in  the  physical  sense  too  elastic,  and 
on  account  of  the  danger  of  perforation.  We  must  have  the  various 
sizes'  of  sounds  at  hand,  preferably  ISTos.  13  to  30  of  Charriere's 
scale,  so  that,  if  necessary,  we  can  employ  progressively  smaller 
sounds.  It  is  to  be  regretted  that  the  thinner  the  instrument  is  the 
more  do  we  lose  the  necessary  feeling  of  resistance  ;  and  when  the 
sounds  have  only  the  diameter  of  a  quill  it  is  impossible  to  decide 
whether  in  a  given  case  we  are  pushing  the  instrument  on,  or 
whether  it  has  been  bent  or  twisted  like  a  corkscrew.  For  this  rea- 
son alone  the  oesophageal  or  stomach  tubes  are  preferable  to  the 
sounds,  from  which  they  difEer  by  being  hollow  and  having  an  eye- 
let on  either  side  of  the  tube  above  its  blunt  extremity.  While  they 
serve  the  same  purpose  for  sounding,  we  can  readily  tell,  by  pouring 
in  fluid,  whether  we  have  passed  the  constriction  or  are  still  above 
it,  and  this  even  with  the  smallest  tubes.  But  they  also  possess  the 
advantage  that  after  we  have  succeeded  in  passing  one  through  the 
oesophagus  (no  matter  what  the  disease  may  be),  we  can  immediately 
thereafter  pour  nourishing  foods  into  the  stomach.  This  is  an  ad- 
vantage which  is  not  to  be  underestimated,  for  it  is  often  a  matter 
of  accident  whether  the  tube  glides  into  the  stomach  or  not.  For 
this  reason,  in  sounding  the  oesophagus,  I  invariably  employ  the  so- 
called  feeding-tube,  with  a  funnel-shaped  enlargement  at  the  upper 
end,  so  that,  if  necessary,  I  can  at  once  introduce  fluid. 

Finally,  the  fenestrated  tubes  have  another  advantage  in  that 
the  edges  of  the  openings  not  infrequently  shave  ofi  particles  of 
tissue  which  would  not  have  been  caught  m  the  sponge.  As  a 
matter  of  course,  the  soft-rubber  tubes  are  not  applicable  for  sound- 
ing the  oesophagus  or  possibly  for  overcoming  strictures,  since  a 
certain  amount  of  rigidity  is  requisite  for  that  purpose.  Yet 
the  soft  tube,  open  at  the  lower  end,  has  several  times  proved 
itself  of  advantage  to  me  in  cases  of  cancerous  stricture,  since  par- 
ticles of  the  neoplasm  were  forced  into  it  by  the  patient's  gagging 
or  coughing  when  the  tube  was  introduced  as  deeply  as  possible, 
and  the  point  consequently  either  impinged  upon  the  tumor  or  in- 
sinuated itself  into  the  funnellike  constriction.  Such  particles  had 
not  become  adherent  at  previous  attempts  either  to  the  sponge  or  to 
the  rigid  fenestrated  sound. 


SOUNDING   OF   (ESOPHAGUS.  127 

Concerning  tlie  use  of  rigid  bougies  or  tubes,  I  must  not  neglect 
to  state  explicitly  that  even  with  careful  manijpulation  the  jposs'Me 
danger  of  causing  a  ])erf oration  is  never  absolutely  excluded. 
Abercrombie  reported  sucli  a  perforation.  As  a  warning,  Yon 
Frericlis  in  bis  lectures  always  cited  a  case  in  wbicb  an  unrecog- 
nized aneurism  of  the  thoracic  aoi-ta  was  tbe  cause  of  obstruction  to 
deglutition.  A  rigid  sound  was  introduced,  and  tbe  point  perfo- 
rated tbe  wall  of  tbe  oesophagus  adjacent  to  tbe  aneurism,  wbicb 
bad  been  tbinned  by  it,  and  also  tbe  aneurismal  sac,  tbus  producing 
fatal  bsemorrbage.     I  myself  saw  tbe  following  case  : 

A  gentleman,  forty-five  years  of  age,  had  sufPered  for  some  time  with 
lancinating  pains  coming  on  in  attacks  and  located  in  the  mediastinal 
region  back  of  the  ensiform  cartilage.  At  the  acme  of  the  attack  the 
pain  was  so  unendurable  that  it  could  only  be  allayed  by  large  injections 
of  morphine.  He  acquired  the  morphine  habit  and  had  subjected  himself 
to  treatment  for  this.  For  a  time  the  paroxysms  were  less  severe,  but 
they  then  reappeared  as  intense  as  before.  Inasmuch  as  there  was  no 
objective  reasons  for  these  pains,  the  cause  was  suspected  to  be  a  psychical 
one,  hysteria;  syphilis  was  also  thought  of,  although  syphilitic  new- 
growths  usually  cause  very  little  or  no  pain,  and  antisyphilitic  treatment 
was  without  result.  Then  later  on  there  appeared  difficulties  connected 
with  eating,  the  food  seeming  to  remain  above  the  stomach  ;  his  appetite, 
which  had  been  capricious  for  a  long  time,  now  disappeared  entirely,  and 
he  lost  considerable  strength.  Fever  was  never  present.  At  times  he 
expectorated  muco-pus  containing  no  elastic  fibers — this  was  before  the 
era  of  bacilli.  Sounding  the  oesophagus  was  suggested.  Percussion 
showed  the  heart  dullness  to  be  abnormally  increased,  extending  on  the 
right  to  the  right  margin  of  the  sternum,  above  and  on  the  left  to  the 
lower  border  of  the  third  rib  ;  no  murmurs  ;  radial  i^ulse  regular,  equal  on 
both  sides ;  the  back  showed  no  dullness  or  sound  of  any  kind,  except 
signs  of  a  slight  catarrh.  In  view  of  this,  and  of  the  attacks  of  pain, 
and  the  remaining  general  conditions,  I  suspected  a  mediastinal  tumor, 
perhaps  an  aneurism,  and  therefore  advised  against  the  introduction  of 
the  sound. 

Two  nights  afterward  the  patient  had  a  terrific  hsemorrhage,  consist- 
ing of  pure  blood,  not  frothy,  which  "  seemed  as  though  it  gushed  from 
the  mouth,"  and  he  died  in  a  few  moments.  Although  an  autopsy  was 
not  allowed,  there  can  be  no  doubt  that  a  large  blood-vessel  had  perforated 
into  the  oesophagus,  and  it  is  equally  certain  that  the  blame  would  right- 
ly or  wrongly  have  been  ascribed  to  a  previous  sounding  had  it  been  un- 
dertaken. 

I  have  already  narrated  a  similar  case  on  p.  15.  Just  sucb  cases 
warn  us  to  be  cautious  xmder  all  circumstances  in  making  an  exam- 
ination with  tbe  sound,  and  one  cannot  take  too  much  trouble  in 


128  DISEASES   OP   THE  STOMACH. 

always  assuring  himself  in  tlie  most  careful  manner  of  the  condi- 
tion of  the  heart  and  its  adnexa  before  exploring  the  cesophagus  or 
stomach  with  the  sound.* 

The  following  case  of  stenosis  of  the  cardia  may  serve  to  illus- 
trate what  has  been  said  above,  and  I  annex  the  discussion  of  diag- 
nosis and  therapy  thereto : 

Mr.  P.,  restaurateur,  forty-eight  years  old,  is  a  man  of  large  and 
powerful  build.  At  a  glance  it  is  evident  that  he  must  lately,  and  in  a 
comparatively  short  time,  have  lost  considerable  flesh.  Not  that  his  face 
has  emaciated  so  much,  but  that  his  clothes  undoubtedly  were  cut  for  a 
much  stouter  man.  Indeed,  he  says  that  he  has  fallen  off  markedly 
only  for  the  past  ten  weeks,  because  he  has  suffered  from  ''stomach 
trouble "  of  constantly  increasing  severity.  Without  any  warning  a 
sensation  was  developed  as  if  the  food  after  eating  were  held  fast  in  the 
region  of  the  stomach  "  as  if  by  a  cork  " ;  this  feeling  disappeared  only 
after  he  had  emptied  his  stomach  by  vomiting.  In  the  beginning  this 
took  place  only  after  a  meal,  but  lately  he  has  had  to  vomit  even  when 
he  had  not  eaten  anything.  The  stomach  is  more  apt  to  retain  fluids 
and  very  soft  articles  of  food,  but  he  is  forced  to  vomit  a  portion 
even  of  these.  The  vomited  masses  have  always  been  only  slightly 
changed,  and  mixed  with  large  quantities  of  tough  mucus.  No  pain  or 
belching.  Appetite  good.  Bowels  somewhat  constipated,  but  easily  regu- 
lated by  cathartics.  Lately  a  marked  feeling  of  weakness  has  developed, 
and  the  patient  spends  the  greater  part  of  the  day  lying  down. 

No  family  history  of  cancer.  Father  died  of  paralysis  ;  mother  is  still 
living.  Physical  examination  of  the  gastric  region  in  the  patient  is 
entirely  negative ;  the  abdominal  walls  are  slightly  retracted ;  percussion 
shows  that  neither  the  stomach  nor  the  neighboring  organs,  liver,  spleen, 
and  intestines,  are  of  abnormal  size.  Palpation  is  also  negative  regarding 
a  tumor  or  any  other  abnormity  in  the  abdominal  cavity.  The  greater 
curvature  apparently  crosses  the  mid-line  2  centimetres  [|  inch]  above  the 
umbilicus.  At  the  same  time  distention  of  the  colon  from  the  rectum,  by 
means  of  the  double  bulb  of  a  spray  apparatus,  shows  that  the  transverse 
colon  immediately  appears  as  a  swelling  under  the  free  border  of  the  ribs ; 
therefore,  at  any  rate,  no  enlargement  of  the  stomach  can  exist.  The 
oesophageal  sound  passes  with  ease  through  the  entrance  of  the  oesopha- 
gus, and  through  its  entire  length;  but  after  it  is  introduced  44  centi- 
metres [17|  inches]  it  impinges  upon  a  firm  obstruction,  just  as  if  its 
point  had  struck  against  the  bottom  of  a  sack.  This  makes  the  patient 
force  up  a  large  quantity  of  a  white,  mucous  fluid,  mingled  with  single 
lumps  of  tough,  glassy  mucus.  It  produces  no  pain,  occasioning  rather 
severe  choking  by  reflex  irritation.  All  efforts  to  pass  the  sound  further 
are  fruitless,  in  spite  of  our  using  sounds  of  different  calibers  down  to  that 
of  a  goose  quill.    No  change  is  produced  by  varying  the  posture  of  the 

*  [See  Discussion  in  Deutsch.  med.  Wochenschr.  Vereins  Beilage,  August  1, 
1895,  p.  130.— Ed.] 


CANCER  OF  CARDIA.  129 

patient  to  the  right  or  left  side  or  to  the  knee-elbow  position.  While  in 
the  latter  position  I  again  palpated  the  abdomen,  but  was  still  unable  to 
detect  any  abnormities. 

Examination  of  the  fluid  brought  up,  amounting  to  about  100  c.  c. 
[f§iij],  gives  the  following  result:  Reaction  with  blue  and  red  litmus 
paper  is  neutral ;  it  gives  a  light  burgundy-red  color  with  iodine,  contains 
sugar,  and  has  a  slight  diastatic  action ;  salts  of  lactic  acid  present  in 
minute  quantities  ;  peptone  and  pepsin  entirely  absent.  Even  after  acidu- 
lating the  fluid,  mixing  it  with  albumen  and  warming,  it  possesses  no 
digestive  action.  The  unchanged  disk  of  albumen  lies  at  the  bottom 
of  the  test  tube,  and  the  biuret  reaction  gives  a  negative  result. 

Under  the  microscope,  in  addition  to  numerous  starch  granules  which 
have  been  colored  blue  by  the  iodine,  we  find  a  few  muscular  fibers  en- 
tirely intact,  and  numbers  of  fat  cells  of  various  sizes.  Rod-shaped  ba- 
cilli are  present  in  small  numbers.  On  the  other  hand,  we  do  not  find  any 
yeast  cells  or  sarcinae,  or  any  cellular  elements  which  might  originate  from 
a  possible  tumor.  The  patient  tells  us  that  about  three  hours  ago  he  took 
some  milk,  and  that  some  time  before  he  had  a  small  quantity  of  scraped 
meat.  On  auscultating  in  the  infrasternal  depression  we  can  not  hear 
any  deglutition  murmurs,  neither  a  first  nor  a  second  sound  being  pres- 
ent ;  but  by  listening  at  the  neck,  after  swallowing,  we  can  distinctly  hear 
the  fluid  passing  down  without  being  able  to  appreciate  the  so-called 
"  stenosis  murmur,"  which  sounds  as  though  the  fluid  were  being  forced 
through  a  narrow  spot. 

Consequently  there  can  be  no  doubt  that  we  have  to  deal  with  a 
case  of  stenosis  of  the  cardia,  and  a  consecutive  dilatation  of  the 
o&sophagus  above  this.  This  is  proved  not  only  by  the  examination 
with  the  sound  and  the  negative  results  of  all  exploratory  proced- 
ures directed  toward  the  stomach,  but  also  by  the  results  of  the 
chemical  examination. 

I  lay  especial  stress  upon  the  chemical  examination  because  its 
results  may  have  enough  weight  to  turn  the  scale  in  a  doubtful  case 
The  following  case  may  serve  as  a  proof  of  this : 

Mrs.  S.,  sixty-two  years  old,  suffered  with  carcinoma  of  the  stomach 
and  liver.  On  passing  the  sound,  she  showed  great  similarity  to  the  case 
we  are  considering  in  regard  to  the  resistance  met  by  the  instrument. 
Here,  too,  the  sound  struck  an  impassable  barrier  at  the  level  of  the  ensi- 
form  process.  Immediately  above  this  I  had  the  unmistakable  im- 
pression of  having  passed  a  constricted  spot,  and  after  this  was  overcome 
there  followed  the  hissing  sound  of  air  escaping  from  the  stomach.  The 
cause  of  this  resistance  offered  to  the  sound  remained  doubtful  during 
life. 

The  autopsy  showed  that  a  very  large  tumor  growing  up  from  the 
retroperiton^um  had  encircled  the  cardia  and  had  lifted  the  fundus  of 
the  stomach  horizontally  upward,  so  that  to  a  certain  extent  two  divi- 


130 


DISEASES  OP  THE  STOMACH. 


sions  of  the  stomach  were  formed,  one  horizontal  and  one  vertical.  The 
sound  impinged  upon  the  bottom  of  the  former.  That  the  condition 
may  be  more  thoroughly  comprehended,   the  two  accompanying  half 

schematic  illustrations  (Figs.  24 
and  25),  made  by  me  at  the  au- 
topsy, are  here  inserted. 

Similar  conlitions  might 
also  be  present  in  our  case, 
or,  as  Quincke*  lias  shown,  a 
kind  of  valve  may  be  formed 
by  an  ulcer  of  tlie  oesophagus, 
which  would  prevent  the  intro- 
duction of  the  sound.  But 
while  in  that  case  the  masses 
which  came  up  through  the 
tube  always  contained  pepsin 
and  several  times  also  peptone 
and  repeatedly  showed  a  yel- 
lowish-green color  due  to  ad- 
mixture with  bile,  the  present 
case  is  absolutely  negative  in 
this  regard.    This  is  proof  posi- 

Fia.  24.-Stomach  of  Mrs.   S.,  died  June  30,    ^^^  that  they  do  not  COme  from 
1887.     Side  view,  to  show  the  cardia  and     the  cavity  of  the  stomacll. 
cul-de-Boc  surrounded  by  the  new  growth.  -^ «  , .  <       ,  i  £     i. 

If  according  to  these  facts 
there  can  be  no  doubt  about  the  existence  of  stricture  of  the  cardia, 
its  nature  and  cause  are  not  less  positively  to  be  estabhshed. 

Among  the  many  causes  which  we  must  consider  as  producing 
the  stenosis  in  our  patient,  one  may  be  at  once  excluded,  and  that  is 
cicatricial  stricture  of  the  oesophagus.  He  has  never  swallowed  cor- 
rosive fluids ;  he  does  not  remember  having  taken  food  hot  enough 
to  cause  the  well-known  burning  sensation  at  any  part  of  the  digest- 
ive tract  down  to  and  into  the  stomach,  although  his  occupation, 
that  of  a  restaurateur,  would  offer  a  certain  inducement  therefor. 
He  has  never  experienced  pressure  or  a  blow  on  the  chest ;  no  sign 
points  to  disease  of  the  organs  of  respiration  or  circulation  or  of  the 

*  Quincke.  Klappenbildung  an  der  Cardia.  Deutseh.  Arch,  fiir  kiln.  Med,, 
1883,  Bd.  xxxi,  S.  408. 


CANCER  OF   CARDIA.  131 

bones.  He  has  had  no  fever.  There  can  be  no  thought  of  a  spastic 
contraction,  judging  from  the  history  and  the  objective  symptoms. 
We  may  exclude  a  diverticulum,  because  diverticula  are  always  situ- 
ated in  the  upper  portion,  chiefly  the  upper  third,  of  the  oesophagus, 
and  never  occur  as  low  down  as  the  cardia. 


Fig.  25.— Stomach  of  Mrs.  S.,  died  June  30,  1887.    Front  view,  showing  cancerous  nodules 
on  the  anterior  surface  of  the  liver,  the  head  of  the  pancreas,  and  the  cardia. 

Thus  by  exclusion  we  would  arrive  at  the  assumption  of  a 
carcinomatous  stricture  of  the  cardia.  It  is  true  that  positive 
evidence  is  entirely  lacking  ;  yet  its  absence — above  all  the  ab- 
sence of  enlarged  glands,  the  deficient  proof  of  carcinomatous 
tissue  elements,  the  freedom  from  all  pain,  and  the  relatively 
moderate  loss  of  muscular  tissue  and  of  strength — does  not  op- 
pose it. 

Only  a  short  time  ago  I  saw  a  case  almost  the  exact  counterpart 
of  the  present  one,  differing  from  it  only  in  that  loss  of  flesh  and 
strength  had  advanced  much  further.  Here,  too,  there  was  no  posi- 
tive evidence  of  cancer,  either  from  the  history  or  on  physical  ex- 
amination. At  times  the  stricture  would  admit  small  sounds,  but 
as  a  rule  they  could  not  be  passed.     "We  made  an  artificial  gastric 


133  DISEASES  OP  THE  STOMACH. 

fistula  in  this  patient,  and  at  the  operation  we  had  the  opportunity 
of  palpating  the  stomach  and  the  surrounding  viscera  through  the 
abdominal  wound.  We  could  very  plainly  palpate  a  tumor  in  the 
region  of  the  cardia  beneath  the  diaphragm,  which  felt  to  be  about 
as  wide  as  a  finger,  somewhat  flattened,  and  inclosing  the  cardiac 
opening  like  a  ring.  Several  weeks  after  the  operation  the  patient 
died  while  absent  from  Berlin,  and  although  it  is  to  be  regretted 
that  an  autopsy  was  not  held,  yet  the  diagnosis  of  cancer  in  this 
case  is  as  firmly  established  as  though  it  had  been  made  by  ocular 
inspection. 

Thus  also  in  our  patient,  as  so  frequently  occurs  in  making  a 
diagnosis,  the  proper  estimation  of  negative  data  is  nearly  as  im- 
portant as  the  positive  results  of  examination,  and  we  are  justified 
in  making  a  diagnosis  of  ca/rcinomatous  stricture  of  the  cardia. 
Whether  it  lies  within  or  without  the  lumen  is  a  question  which  we 
must  leave  unsettled. 

There  still  remains  a  condition  to  be  discussed  which  is  nearly 
always  a  result  of  stricture  of  the  oesophagus  or  the  cardia  of  long 
duration,  and  that  is  dilatation  of  the  oesophagus  above  the  constricted 
spot.  But  since  a  prolonged  reaction  of  the  narrowed  portion  upon 
the  parts  above  is  necessary  for  their  formation,  we  can  easily 
understand  the  rare  occurrence  of  such  secondary  dilatation  in  cases 
of  carcinomatous  stricture,  which,  as  a  rule,  cause  death  too  rapidly. 
However,  the  dilatation  existing  in  the  above-described  case  must 
have  reached  a  considerable  size,  otherwise  it  would  not  be  conceiv- 
able how  it  could  hold  100  c.  c.  [f  §  iij  3  ij]  and  over.  ]!^aturally 
this  can  only  take  place  at  the  expense  of  the  neighboring  viscera 
by  compressing  or  displacing  them. 

Dilatations  situated  above  a  constricted  spot,  as  a  rule,  tend  to 
involve  the  whole  circumference  of  the  gullet,  and,  after  existing 
for  some  time,  to  cause  complete  atrophy  of  the  mucous  membrane, 
while  the  muscularis  is  thinned  and  its  fibers  separated  into  wide 
meshes.  By  tliis  I  do  not  mean  to  say  that  the  dilatation  may  not 
develop  more  in  a  certain  direction  and  in  this  way  gradually  lead 
to  the  formation  of  a  true  pocket.  For  this  purpose  there  is  needed 
only  a  somewhat  greater  yielding  of  the  oesophageal  muscle  fibers 
to  the  pressure  of  masses  of  food.     Such  a  case  was  observed  by 


SPASMODIC  CONTRACTION  OP  CARDIA.  133 

!Nico]adoni  *  in  a  four-year-old  girl,  who  had  a  stricture  of  the 
oesophagus  due  to  corrosion.  The  stricture  was  8  centimetres  [3^ 
inches]  long,  and  above  it  the  oesophagus  was  irregularly  bellied  out 
for  a  distance  of  2^  centimetres  [1  inch],  chieilj  on  the  anterior 
wall  and  to  the  left,  so  that  there  existed  a  saccular  dilatation  which 
was  sharply  shut  off  from  the  stricture,  and  in  which  one  could 
easily  introduce  the  entire  last  jDhalanx  of  the  forefinger.  Under 
such  conditions — that  is,  when  the  stricture  is  not  immediately 
above  the  cardia,  but  is  situated  higher  up  in  the  gullet — partial 
dilatations  may  give  the  first  impetus  to  the  formation  of  a  diver- 
ticulum, for  which  there  is  no  room  immediately  above  the  dia- 
phragm. 

Wheatley  Hart  f  describes  the  case  of  a  woman,  fifty-eight  years 
old,  who  had  for  twenty  years  suffered  with  dysphagia,  connectei 
with  frequent  vomiting,  and  who  gradually  died  of  marasmus.  The 
autopsy  showed  the  following :  The  stomach,  the  mucous  membrane 
of  which  showed  no  abnormalities,  was  small  and  its  mouth  so  nar- 
row that  the  httle  finger  could  only  be  introduced  with  difiiculty ; 
but  there  was  neither  thickening  nor  hardening  of  the  tissue  at  this 
place.  Above  this  the  oesophagus  was  enormously  dilated,  so  that 
on  the  right  side  of  the  spine  it  lay  in  the  hollow  of  the  ribs,  where 
it  was  fairly  bent  at  a  right  angle  and  directed  toward  the  foramen 
diaphragmaticum.  On  its  removal  it  looked  like  a  second  stomach, 
and  could  hold  750  grammes  [  f  xxv]  of  fluid.  The  muscularis  was 
greatly  hypertrophied.  Hart  believes  that  it  was  originally  attached 
to  the  lungs  and  pericardium,  but  that  it  was  afterward  separated  by 
a  retracting  pleuritis  and  mediastinitis,  since  both  processes  were 
found  markedly  developed. 

Spasmodic  contractions  of  the  oesophagus  or  cardia  of  long 
standing  may  also  cause  dilatation  of  the  portion  of  the  gullet  lying 
above  them.  Leichtenstem  :{:  has  reported  a  well-marked  example 
of  this  in  a  patient  who  had  suffered  for  seven  years  from  obstinate 

*  Nicoladoni.     Wiener  raed.  Wochenschr.,  1877,  No.  25. 

f  Wheatley  Hart.  Autopsy  on  a  Case  of  Prolonged  Vomiting.  Lancet,  1883, 
ii,  p.  456. 

4  Leichtenstem.  Enorme  saekartige  Erweiterung  des  Oesophagus  ohne  me- 
chanisehe  Stenose  desselben  in  einem  Falle  von  siebenjahrigem  hysterischen  Er- 
breehen.     Deutsch.  med.  Wochenschr.,  1891,  No.  4. 


134  DISEASES   OF   THE  STOMACH. 

liysterical  vomiting.  A  similar  case  lias  been  observed  by  Einbom,* 
who  could  only  overcome  tbe  spasm  of  the  cardia  by  forced  pressure 
with  the  glottis  closed  and  the  head  thrown  back.  If  he  thus  suc- 
ceeded in  getting  some  coffee  or  claret  into  the  stomach,  and  imme- 
diately thereafter  gave  a  glass  of  water,  the  latter  could  be  removed 
unchanged  from  the  lower  portion  of  the  oesophagus,  although,  with 
a  tube  introduced  into  the  stomach,  chyme  containing  HCl  could 
be  obtained. 

One  of  my  patients,  in  whom  there  was  a  condition  entirely 
analogous  to  that  existing  in  the  case  under  discussion,  complained 
of  severe  dyspnoea  as  soon  as  he  made  any  extra  demands  upon  his 
respiratory  organs,  even  in  walking  from  one  room  to  another  a 
little  faster  than  usual  or  on  going  upstairs.  The  patient.  P.,  whose 
case  I  have  just  described,  was  so  short  of  breath  the  first  time  he 
visited  me  that  at  the  first  glance  I  took  him  to  be  suffering  with 
pulmonary  or  cardiac  disease.  This  condition  may  be  primarily 
ascribed  to  the  general  weakness  of  the  patient,  but  it  can  in  part 
be  referred  to  purely  mechanical  causes — to  compression  of  the 
lungs,  and  possible  displacement  of  the  heart. 

The  treatment  of  the  case  described  above  is  clearly  indicated. 
Inasmuch  as  the  stricture  is  entirely  or  practically  impassable,  and 
since  internal  medication,  even  if  we  possessed  specific  remedies, 
would  thus  be  of  no  avail,  and  since  mechanical  dilatation  is  im- 
possible, there  remain  only  rectal  alimentation  and  the  production 
of  a  gastric  fistula.  Although  rectal  ahmentation  is  very  valuable 
for  a  short  while,  it  is  not  effective  for  long  periods  of  time,  and 
therefore  if  the  entrance  to  the  stomach  is  closed  to  all  kinds  of 
food  or  nourishing  materials  it  is  to  be  combined  with  gastrostomy. 
We  shall  perform  this  operation  in  our  case,  and,  if  possible,  we 
shall  attempt  bloodless  dilatation  of  the  constricted  portion,  working 
from  within  the  stomach. 

The  patient  whose  history  I  have  given  in  detail  above,  on  whom 
•gastrostomy  was  to  be  performed  because  of  our  diagnosis  of  can- 
cerous stricture  of  the  cardia,  was  operated  on  by  Prof.  Sonnen- 

*  Einhorn.     Pall  von    Dysphagie    mit    Oesophagusdilatation.     Wiener    med. 
Presse,  1890,  No.  3. 


STENOSIS   OP   CARDIA.  135 

burg  five  days  later.  Reserving  the  remarks  concerning  tlie  opera- 
tion kindly  placed  at  my  disposal  by  Prof,  Sonnenburg  for  the  end 
of  tbis  cbapter,  I  wisb  now  to  state  that  we  palpated  the  stomach 
after  the  abdominal  cavity  was  opened,  but  were  imable  to  recog- 
nize any  abnormity. 

Two  days  later,  when  the  fistula  had  been  established,  it  was  seen 
that  with  the  exception  of  some  mucus  the  stomach  was  empty. 
This  mucus  gave  a  neutral  reaction  to  strips  of  htmus  paper  which 
were  introduced. 

For  the  first  three  days  after  the  formation  of  the  fistula  the  condition 
of  the  patient  was  excellent.  He  complained  only  of  a  feeling  of  pres- 
sure, but  retained  the  nutrient  enemata  given  to  him.  and  the  souj)  poured 
in  thi'ough  the  fistula.  On  the  fourth  day  he  began  to  cough  a  little  and 
to  bring  up  slightly  fluid,  greenish-yellow  sputum,  which  contained 
small,  whitish  particles  about  the  size  of  a  grain  of  sand  or  the  head  of  a 
pin.  The  cough  increased  in  frequency  and  severity,  chiefly  at  night, 
and  could  not  be  relieved  by  subcutaneous  injections  of  morphine.  A 
penetrating  odor  from  the  mouth  became  noticeable,  and  the  evening 
temperature  rose  to  39 "2°  C.  [102'5°  F.].  Examination  of  the  sputum  re- 
vealed numerous  pus  cells,  free  nuclei,  bacteria,  and  masses  of  cocci,  but 
no  tubercle  bacilli  and  no  elastic  fibers.  The  minute  particles  mentioned 
above  consisted  of  large  numbers  of  short,  rod-shaped  bacilli,  so  that  they 
almost  represented  a  pure  culture.  An  ineffectual  attempt  was  made  to 
check  the  putrid  decomposition  by  giving  the  patient  capsules  of  salicylic 
acid  to  swallow  and  by  washing  out  the  oesophagus  vs^ith  a  solution  of 
the  same  drug.  Dullness  and  bronchial  breathing  appeared  over  the 
lower  portions  of  both  lungs  posteriorly.  Elastic  fibers  were  now  found 
in  the  sputum,  and  a  diagnosis  of  double  pleuro-pneumonia  due  to  per- 
foration or  swallowing  was  made.  The  fever  continued,  the  patient's 
strength  rapidly  failed,  and  he  died  on  the  eighth  day  after  the  operation 
in  a  mildly  somnolent  state. 

The  autopsy  which  I  made  revealed  the  following : 

Fundus  of  the  stomach  lies  in  the  hollow  of  the  diaphragm.  It  meas- 
ures 12  centimetres  [4|  inches]  in  its  widest  portion,  and  30  centimetres 
[12  inches]  from  the  pylorus  to  the  cardia.  The  organ  when  cut  open  has 
a  transverse  diameter  of  19  centimetres  [7|  inches].  The  opening  of  the 
fistula  is  6  centimetres  [2f  inches]  above  and  to  tbe  right  of  the  ring  of  the 
pylorus.  Its  edges  are  puffed  up,  so  that  the  mucous  membrane  lies  quite 
smoothly  over  the  muscularis  toward  the  outer  side.  From  without  the 
pylorus  feels  swollen  and  thickened.  On  cutting  open  the  viscus  we  see 
that  this  is  caused  by  a  trabecular  thickening  of  the  submucous  connect- 
ive tissue,  while  the  muscularis  and  serosa  are  not  involved. 

Even  from  without  we  can  see  that  the  oesophagus  above  the  cardia  is 
converted  by  a  dilatation  measuring  6  to  7  centimetres  [2|  to  2|  inches] 
10 


136  DISEASES  OF  THE  STOMACH. 

into  a  hard,  sausagelike  mass.  On  introducing  a  thin  glass  rod  it  either 
enters  a  pocket,  in  which  it  is  arrested,  or  it  passes  through  a  narrow 
canal  into  the  stomach.  Water  poured  in  from  above  slowly  flows  into 
the- stomach  after  first  having  rapidly  filled  the  oesophagus.  The  latter  is 
widened  above  the  tumor,  so  that  at  a  distance  of  5  centimetres  [2  inches] 
from  the  upper  margin  it  has  a  diameter  of  6  centimetres  [2|  inches]  ;  then 
it  gradually  becomes  narrower,  and,  13  centimetres  [5^  inches]  higher  up, 
is  only  3  centimetres  [1^  inches]  wide.  Opening  the  oesophagus,  we  see 
that  the  growth  commences  exactly  at  the  cardia  and  that  the  incision 
has  separated  it  into  a  larger  (right)  and  smaller  (left)  ovoid  portion  with 
only  a  very  narrow  canal — admitting  a  thin  pencil — between  them,  which 
is  further  marked  by  warty  polypoid  excrescences.  The  growth  is  so  fri- 
able that  the  right  side  tears  apart  lengthwise,  thus  opening  an  empty 
cavity  or  cleft  lined  with  a  greenish -gray,  fairly  firm  membrane  (Fig.  26). 
Under  the  surface  of  the  mucous  membrane  of  the  oesophagus  are  single 
small  punctate  nodules,  appearing  faintly  white  through  the  mucous 
membrane,  the  epithelium  of  which  is  desquamated  in  shreds  as  though 
it  had  been  corroded.  The  same  condition  exists  immediately  below  the 
tumor,  where  it  passes  on  to  the  mucous  membrane  of  the  stomach.  The 
latter  membrane  is  smooth  at  the  fundus  and  of  a  pretty  pink  color.  In 
the  remaining  portions  it  is  thrown  into  very  many  folds  and  is  more  of  a 
slate  color.  No  punctate  haemorrhages  or  suggillations.  The  left  side  of 
the  oesophagus  corresponding  to  the  exx^ansion  of  the  tumor  is  attached  to 
the  mediastinum  and  the  pulmonic  pleura  by  a  recent  adhesive  inflam- 
mation. A  lymphatic  gland,  situated  above  and  to  the  left  of  the  dia- 
phragm, is  slightly  tumefied,  and  on  section  shows  commencing  punctate 
suppuration. 

The  lower  lobes  of  both  lungs  are  swollen,  of  a  marked  reddish-brown 
color,  and  are  absolutely  unaerated.  The  upper  lobes  and  the  middle 
one  of  the  right  lung  are  aerated,  and  the  pleura  covering  the  two  lower 
lobes  shows  a  recent  slight  fibrinous  deposit.  We  further  find  sharply 
circumscribed  round  spots  of  a  light  greenish -yellow  color  like  pus,  chiefly 
at  the  base  of  the  right  lung.  They  are  less  numerous  on  the  posterior 
surface  of  the  lower  lobes  of  the  right  and  left  lungs.  Their  size  varies 
from  that  of  a  lentil  to  that  of  a  pea.  On  cutting  into  them  we  discover 
that  they  correspond  to  little  hollows  with  a  membranous  lining  and 
filled  with  a  smeary,  greenish-yellow  mass  having  a  penetrating  and 
most  offensive  odor.  A  bronchus  or  bronchiole  can  be  traced  to  each 
hollow.  The  mucous  membrane  of  the  bronchi  is  dark  bluish  red  in 
color,  like  satin,  swollen,  and  filled  with  quantities  of  frothy,  blood- 
streaked  pus. 

All  the  other  organs  are  normal. 

The  small  intestines  are  unusually  firmly  contracted,  so  that  they  are 
scarcely  the  size  of  a  finger. 

A  fresh  particle  of  the  tumor  scraped  from  its  surface  shows  the  most 
varied  forms  of  cylindrical  and  pavement  epithelium,  round  cells  with 
large  nuclei,  and  masses  of  cocci.  Microscopic  examination  of  the  hard- 
ened tumor  reveals  an  epithelioma  extending  down  to  the  serosa,  with 
portions  of  its  elements  undergoing  degeneration. 


STENOSIS  OF  CARDIA. 


137 


Fig.  26.— Carcinoma  of  oesophagus  just  above  the  eardia.    Mr.  P.  died  August  3, 1887. 
a,  oesophagus  ;  b,  eardia ;  c,  cavitj;  of  stomach. 


138  DISEASES   OP   THE   STOMACH. 

In  this  record  of  the  autopsy  the  patency  of  the  stricture  estab- 
lished post  mortem  does  not  seem  to  correspond  to  the  complete 
closure  existing  during  life.  If  we  consider,  though,  that  the  tissues, 
losing  their  turgescence,  shrink  after  death,  we  can  easily  explain 
how  during  life  the  narrow  canal  was  completely  displaced  and  oc- 
cluded between  the  masses  of  the  growth.  At  any  rate,  the  opera- 
tion was  not  only  fully  indicated,  but  it  would  have  offered  the  best 
chances  for  the  patient  had  not  the  gangrenous  aspiration  pneu- 
monia {ScJiluckpneumonie]  intercurred.  This  is  an  accident,  pre- 
vention of  which  lies  beyond  our  power.  A  woman  with  carcinoma 
of  the  oesophagus,  on  whom  gastrostomy  was  performed  also  by  Prof. 
Sonnenburg,  was  in  as  good  condition  five  months  after  the  opera- 
tion as  the  circumstances  could  possibly  permit,  in  spite  of  the  fact 
that  five  years  previously  her  right  breast  had  been  amputated  and 
the  right  arm  disarticulated  subsequently  on  account  of  cancer  of 
the  breast.  She  died  finally  of  a  fresh  metastasis  which  developed 
in  the  right  pleura. 

I  could  narrate  many  cases  which  in  their  essential  details  are 

exactly  like  the  one  described,  for  in  the  last  four  years  I  have 

had  twenty -five  cases  *  (five  of  which  were  operated  upon)  in  my 

service  at  the  Augusta  Hospital ;  but  I  shall  refrain  from  doing 

so.     Instead,  I  shall  describe  a  somewhat  rare  case  of  eicatricial 

stenoses  of  the  cardia  following  a  jpeptic  ulcer  of  the  oesophagus. 

Johanna  J.,  nineteen  years  old,  was  admitted  to  sanitarium  on  June 
20,  1891.  She  stated  that  her  parents  were  alive  and  well ;  has  seven 
brothers  and  sisters  who  are  in  good  health.  Her  growth  has  been  re- 
tarded, but  she  had  always  been  well,  with  the  exception  that  while  at 
school  she  frequently  had  colic  and  stomach-ache  after  acid  food.  When 
fifteen  years  old,  after  eating  tainted  meat,  she  vomited  a  number  of  times 
daily;  this  lasted  for  six  months,  and  she  gradually  improved  so  that 
until  her  eighteenth  year  she  vomited  only  once  a  day.  Then  it  ceased  in 
January,  1891 ;  her  digestion  was  good  ;  she  had  daily  evacuations  and  felt 
well.  In  April,  1891,  she  noticed  for  the  first  time  that  the  swallowing  of 
food  was  painful,  the  pain  being  situated  at  the  level  of  the  ensiform 
process.  Then  deglutition  gradually  became  more  difficult,  so  that  poorly 
masticated  food  could  only  be  swallowed  if  she  took  some  fluid  with  it. 
Two  weeks  before  her  admission,  only  fluids  such  as  thin  gruels  could  be 
swallowed.  There  was  never  any  h^matemesis.  She  had  never  men- 
struated. 

*  Numerous  cases  in  dispensary  and  consultation  practice  are  not  included  be- 
cause 1  have  no  complete  records  of  many  of  them. 


CICATRICIAL  STENOSIS  OP  CARDIA.  139 

On  admission  she  was  very  much  emaciated,  and,  although  her  cloth- 
ing was  not  heavy,  weighed  only  25  2  kilogrammes  [55i  pounds].  No 
sound  of  any  kind  could  be  passed  through  the  stricture  of  the  CBSopha- 
gus  ;  on  swallowing  water,  only  a  delayed  and  very  feeble  deglutition 
murmur  could  be  heard.  The  abdomen  was  sunken  ;  no  gastric  succus- 
sion  could  be  obtained.  No  tumor  of  any  kind  or  glandular  enlargements 
could  be  felt.  Urine  abundant  and  normal.  No  evidences  of  syphilis 
could  be  detected  either  from  her  history  or  from  a  thorough  exam- 
ination. 

In  considering  the  various  etiological  factors  of  the  stenosis,  both 
carcinoma  and  syphilis  could  be  excluded  by  the  history  and  examination. 
The  possibility  of  a  hysterical,  spastic  contraction  of  the  oesophagus  could 
not  be  excluded.  But  it  is  characteristic  of  the  latter  condition  that  the 
spasm  can  be  overcome  by  the  use  of  large  bougies  and  a  passage 
effected  after  allowing  them  to  lie  for  some  time.  Furthermore,  other 
signs  of  hysteria  are  never  lacking  in  such  cases.  But  in  our  patient  such 
symptoms  were  absent,  nor  could  anything  be  accomplished  by  the  intro- 
duction of  large  bougies.  Although  a  positive  diagnosis  was  not  possible 
immediately  on  her  admission,  yet  prolonged  observation  made  it  more 
and  more  probable  that  there  was  a  cicatricial  stricture  after  an  ulcer. 
At  all  events  gastrostomy  was  absolutely  indicated  to  prevent  starvation. 

The  operation  was  performed  on  June  20,  1891.  The  stomach,  which 
was  found  to  be  relatively  large,  was  drawn  out  and  was  stitched  to  the 
peritonaeum.  At  the  end  of  the  narcosis  half  a  litre  [one  pint]  of  fluid 
was  vomited,  although  on  the  previous  day  the  patient  had  only  taken 
200  c.  c.  [about  f  |  vij].  On  the  following  days  nutritive  enemata  and 
small  quantities  of  cold  milk  were  given.  General  condition  good.  Five 
days  later  the  stomach  was  opened  with  the  Paquelin  cautery,  without 
narcosis.  The  fluid  which  escaped  contained  large  quantities  of  free  HCl, 
and  had  an  acidity  of  60  per  cent.  Milk  with  softened  bread,  bouillon, 
raw  eggs,  etc.,  were  introduced  into  the  stomach ;  the  wound  was  kept 
open  with  a  small  wooden  plug  surrounded  by  iodoform  gauze.  Subse- 
quent observation  showed  that  the  stomach  emptied  itself  very  slowly,  and 
consequently  some  obstruction  must  exist  at  the  pylorus,  for  even  after  24 
hours  large  quantities  of  stomach  contents  could  be  obtained  on  remov- 
ing the  plug.  Every  examination  showed  an  abundance  of  free  HCl, 
the  acidity  on  different  days  being  81,  102,  and  104  per  cent.  Up  to  the 
beginning  of  July  the  fistula  gradually  grew  larger,  so  that  not  alone 
could  the  index  finger  be  inserted,  but  also  a  small  speculum  by  means  of 
which  the  mucous  membrane  could  be  examined  for  some  distance.  Later 
on  the  fistula  gradually  became  smaller  ;  the  patient  was  nourished  at  first 
through  the  fistula  and  then  also  by  mouth.  She  gained  considerably  in 
weight,  so  that  at  the  end  of  October  she  weighed  31  kgm.  [68  lbs.],  and  a 
year  later  35  kgm.  [77  lbs.]. 

Infiation  of  the  stomach  with  air  through  the  fistula  shows  that  the 
organ  is  displaced  downward,  the  greater  curvature  being  about  a  fin- 
ger's breadth  below  the  umbilicus ;  the  lesser  can  be  distinctly  recog- 
nized below  the  ensiform  process.  The  stomach  has  a  slight  hourglass 
shape,  and,  calculating  from  the  amount  of  air  which  can  be  pumped  in, 
holds  about  700  c.  c.  [23  ounces].     The  orifice  of  the  fistula  lies  just  below 


140  DISEASES  OF  THE  STOMACH. 

the  middle  of  the  left  costal  horder.  If  the  finger  is  inserted  it  can  he 
freely  moved  in  all  directions  without  encountering  any  obstacle.  Even 
after  repeated  efforts,  both  with  a  silver  catheter  and  a  suitably  curved 
tube,  the  pylorus  could  not  be  reached.  A  sound  can  be  introduced 
through  the  fistula  15  ctm.  [6  inches]  upward,  16  ctm.  [6  "4  inches]  down- 
ward and  to  the  right,  and  13  ctm.  [5'  6  inches]  perpendicularly  downward 
in  the  parasternal  line.  In  both  of  the  latter  tests  the  point  of  the  sound 
could  be  distinctly  felt  under  the  abdominal  parietes.  A  thin  bougie 
introduced  through  the  mouth  is  arrested  at  30  ctm.  [12  inches]  from  the 
incisor  teeth  by  an  insuperable  obstruction ;  the  tip  could  not  be  seen 
with  a  speculum  inserted  into  the  fistula.  The  passage  of  the  bougies 
caused  spasmodic  contractions  and  much  nausea,  during  which  the  ori- 
fice of  the  fistula  was  almost  closed. 

At  the  end  of  October,  1893,  the  patient  was  feeling  well  and  was  able 
to  do  housework.  Once  only  there  was  a  slight  transient  disturbance  of 
the  stomach.  The  orifice  of  the  fistula  had  contracted  to  the  size  of  a  lead 
pencil,  and  was  still  closed  with  a  piece  of  wood,  on  the  removal  of  which 
the  stomach  contents  fiowed  out  as  from  a  faucet. 

The  present  appearance  of  the  patient  is  excellent ;  she  has  put  on  flesh 
so  that  it  is  hard  to  conceive  that  she  is  the  same  person  who  18  months 
ago  was  in  such  a  wretched,  half -starved  condition. 

A  word  about  the  diagnosis  of  this  case.  Besides  the  oesopha- 
geal stricture,  there  is  undoubtedly  a  stenosis  of  the  pylorus  which 
has  caused  a  dilatation  of  the  stomach.  The  history  of  the  patient 
does  not  enable  us  to  decide  positively  whether  this  is  due  to  a 
cicatricial  contraction  after  an  ulcer  or  to  an  induration  of  the  py- 
loric muscular  fibers  consecutive  to  a  chronic  catarrh ;  still,  in  view 
of  the  fact  that  she  undoubtedly  had  an  ulcer  in  the  oesophagus,  it 
is  probable  that  she  also  had  an  ulcer  near  the  pylorus.  A  careful 
consideration  of  all  the  facts  as  to  the  obstruction  in  the  oesophagus 
leaves  no  other  explanation  except  that  there  had  been  an  ulcer 
which  had  occupied  the  typical  site,  i.  e.,  just  above  the  cardia,  and 
which  had  gradually  produced  a  cicatricial  stenosis  of  the  oesopha- 
gus. This  stenosis  was  partially  overcome  by  the  passage  of  sounds, 
and  also  by  the  traction  exerted  on  the  scar  by  the  stomacb  when 
full  of  food,  after  the  latter  had  been  rendered  possible  by  the  gas- 
trostomy. The  degree  of  patency  is  such  that  soft,  mushy  food  can 
be  swallowed,  but  coarse  articles  of  diet,  such  as  coarsely  cut  meat 
and  vegetables,  can  not  be  introduced  into  the  stomach. 

Treatment  of  Strictures  of  the  Cardia. — In  all  organic  strictures 
of  the  oesophagus  situated  at  the  cardia  we  can  only  expect  help 
from  operative  procedures.     Kobody  can  believe  that  we  can  obtain 


TREATMENT  OP  STRICTURES  OP  CARDIA.  141 

any  results  with  internal  medication,  the  so-called  resolvent  or  altera- 
tive drngs  of  a  therapy  w^liich  is  not  so  very  ancient,  mercurials  or 
iodine,  or  even  with  the  highly  praised  condurango.  We  can  only 
attemj)t  the  bloodless  dilatation  of  the  stricture  by  means  of  sounds, 
and  where  this  is  impossible  we  must  perform  gastrostomy.  Dilata- 
tion of  the  stenosis  with  bougies  necessarily  presupposes  at  least  a 
partial  penetration  of  the  instrimient  into  the  constricted  portion. 
As  a  rule,  this  will  succeed  at  first  if  the  stricture  be  a  simple  incom- 
plete one  without  secondary  dilatation  of  the  parts  higher  up.  For 
this  we  should  always  use  the  largest  sounds  possible — at  least,  we 
should  always  attempt  to  introduce  the  larger  ones.  The  thinner 
the  sound,  the  greater  the  danger  that  its  fine  point  will  be  caught 
in  the  inequalities  of  the  constricted  spot  or  in  pockets  due  to  sec- 
ondary dilatation,  even  when  these  pockets  are  so  small  that  a  larger 
sound  would  glide  past  them.  In  this,  as  always  occurs  under 
such  circumstances,  chance  may  play  an  important  role ;  at  one 
time  we  may  succeed  in  passing  the  sound,  and  at  another  it  bends 
at  its  point.  I  have  frequently  found  it  to  be  advantageous  to  allow 
the  patients  to  force  down  the  sounds  themselves  to  a  certain  extent 
by  ordering  them  to  make  repeated  efforts  at  swallowing.  It  may 
then  glide  into  the  proper  path,  and  can  be  pushed  on  by  slight 
pressure  from  above. 

The  introduction  of  sounds  too  frequently  or  too  rapidly  re- 
peated is  to  be  guarded  against.  I  have  seen  a  sound  (!No.  20,  Char- 
riere)  pass  through  a  stricture  with  comparative  ease,  but  it  would 
not  do  so  on  the  fourth  or  fifth  day,  since  a  marked  swelling  or  a 
rapid  growth  of  the  affected  parts  had  undoubtedly  been  caused  by 
the  irritation  of  the  sound.  Mackenzie  *  has  also  called  attention  to 
the  same  fact.  We  allow  the  sound  to  remain  in  situ  for  from  three 
to  five  minutes,  and  pass  from  the  smaller  to  the  larger  numbers.  It 
is  disagreeable  to  a  great  many  patients  who  permit  the  sound  to 
pass  easily  to  retain  it  for  this  length  of  time,  principally  on  account 
of  the  copious  secretion  of  saliva.  In  such  cases  I  usually  first  give 
a  subcutaneous  injection  of  1  milhgramme  \_-^-^  grain]  of  atropine  ^ 
with  5  milligrammes  \_-^-^  grain]  of  morphine.     The  salivation  then 

*  Morell  Mackenzie.     Die  Krankheiten  des  Halses  und  der  Nase.     Berlin,  1884, 
pages  130  and  185. 


142  DISEASES  OP  THE  STOMACH. 

ceases  entirely  or  does  not  appear  at  all,  while  the  morphine  in- 
creases the  tolerance  of  the  patient.  Instead  of  the  English  sounds 
we  can  use  a  staff  of  whalebone  with  olive-shaped  ivory  points, 
which  can  be  unscrewed  and  changed  to  larger  or  smaller  sizes  as 
the  occasion  may  demand. 

Thin  English  sounds  with  pyriform  extremities  are  also  made. 
At  Ererichs'  clinic  we  used  long,  smooth  instruments  of  whalebone 
of  various  sizes.  If  the  stricture  is  not  too  marked,  we  can  also  use 
a  soft-rubber  oesophageal  tube  of  the  proper  caliber,  which  is  intro- 
duced into  the  stomach  and  allowed  to  remain  there  for  a  while. 
The  patients  tolerate  this  better  than  keeping  a  stiff  sound  in  place, 
because  they  can  close  their  mouths,  and  they  do  not  have  the 
troublesome  flow  of  saliva ;  moreover,  it  also  seems  to  create  less 
irritation  at  the  affected  spot. 

Senator  *  has  proposed  the  use  of  laminaria  tents  of  various  sizes 
which  are  screwed  to  an  ordinary  oesophageal  bougie,  just  as  olive- 
shaped  bulbs  are  attached  to  a  whalebone  staff ;  they  are  to  be  inserted 
into  the  stricture  which  is  to  be  dilated  by  their  swelling  up.  Al- 
though the  idea  is  a  good  one,  yet  it  has  proved  to  be  impracticable 
because  most  patients  can  not  tolerate  the  tents  long  enough  to  allow 
them  to  swell  up  sufficiently.  Recent  investigations  have  shown  the 
requisite  time  to  be  more  than  two  hours.  Granting  that  the  stric- 
ture is  such  that  a  sound  can  be  pushed  through  it  and  that  its  depth 
has  been  carefully  measured,  there  is  also  some  danger  that  the  in- 
evitable retching  and  attempts  at  swallowing  may  cause  the  tent  to 
be  pushed  below  the  stricture ;  it  will  then  swell  up  and  can  not  be 
withdrawn. 

Rosenheim  f  has  suggested  the  use  of  tin  bougies.  [These  are 
inserted  with  the  aid  of  the  cesophagoscope.] 

[Schreiber  ^  has  devised  a  "  dilatation  sound  "  which  consists  of  an 
oesophageal  tube  to  which  a  closed  piece  of  rubber  tubing  is  attached 
at  the  lower  end ;  by  forcibly  distending  the  tube  with  water  and 


*  Senator.     Therapeut.  Monatshefte,  July,  1889. 

■)•  [Rosenheim.  Krankheiten  der  Speiserohre  unci  des  Magens.  2te  Aufl.,  1896, 
p.  159.— Ed.] 

X  [Schreiber.  Die  Dilatation  Sonde.  Volkmann's  Klinische  Vortrage,  1893,  No. 
85.— Ed.] 


TREATMENT   OP   STRICTURES  OP   CARDIA.  143 

exerting  pressure  by  tlie  expansion  of  the  rubber  tubing,  the  dilata- 
tion is  to  be  slowly  accomplished.  The  method  is  ingenious,  but  re- 
quires much  experience  to  suitably  construct  the  instrument  for 
each  case.] 

Finally,  as  early  as  1843,  Switzer  in  Copenhagen  proposed  the 
use  of  a  permanent  canula,  which  was  used  later  on  by  Krishaber, 
Mackenzie,  Symonds,  and  recently  by  Leyden  and  Eenvers,*  in  the 
form  of  a  kind  of  catheter  a  deineure.  A  slightly  conical  tube,  oval 
on  section,  made  of  hard  rubber,  or  a  soft  rubber  catheter,  to  which 
two  strong  silk  cords  are  attached,  is  introduced  into  the  constricted 
part  by  means  of  a  whalebone  guide  supplied  with  a  proper  obtura- 
tor and  left  there  after  the  withdrawal  of  the  guide.  The  cords 
hang  from  the  mouth  and  are  wound  around  the  ear,  or  they  may 
be  carried  through  the  nose.  If  the  tube  does  not  become  clogged, 
it  is  allowed  to  remain  in  place  as  long  as  fourteen  days.  It  is  then 
removed  and  a  new  one  substituted.  This  procedure  naturally  pre- 
supposes a  certain  size  of  the  stricture,  since  canulas  smaller  than  a 
large  pencil  can  not  be  introduced  well  unless,  like  Mackenzie,f  we 
care  to  forcibly  thrust  the  catheter  through  the  stricture,  which, 
granting  that  it  be  possible,  is  by  no  means  advisable.  Leyden  and 
Renvers,  in  two  cases  in  which  they  diagnosticated  oesophageal  can- 
cer, had  the  good  fortune  to  obtain  excellent  results  by  means  of  a 
permanent  canula — i.  e.,  increase  in  the  patient's  weight  for  a  con- 
siderable time.  In  three  or  four  cases  in  which  the  existence  of  car- 
cinoma of  the  oesophagus  was  proved  by  autopsy,  I  found  that  the 
patients  could  tolerate  the  canula  only  for  a  comparatively  short 
time,  but  that  I  could  produce  a  decided  transient  relief  by  it.  Son- 
nenburg  %  properly  says  that  but  few  cases  are  fit  for  this  procedure, 
which  can  easily  lead  to  rapid  growth  of  the  cancer,  the  occurrence 
of  sudden  hasmorrhages,  necrosis,  perforations,  etc.  When  the  stric- 
ture is  situated  at  the  spot  which  interests  us  at  present — the  deepest 

*  E.  Leyden  and  Renvers.  Ueber  die  Behandlung  carcinomatoser  Oesophagus- 
strictur.  Deutsch.  med.  Wochenschr.,  1887,  No.  50.  [Also,  Renvers.  Die  Be- 
handlung der  Oesophagnsstricturen  mittelst  Dauerkanulen.  Zeitschrift  f.  klin. 
Med.,  Bd.  xiii,  S.  499.— Ed.] 

f  Loc.  cit. 

X  E.  Sonnenburg.  Beitrage  zur  Gastrostomie.  Berl.  klin.  Wochenschrift,  1888, 
No.  1. 


144  DISEASES  OF  THE  STOMACH. 

portion  of  the  CBSophagus — tlie  tube  must  reach  into  the  stomach. 
It  is  doubtful  whether  this  is  possible  without  causing  persistent 
irritation.  At  any  rate,  it  has  not  yet  been  attempted.  The  same 
may  be  said  of  Gersung's  complicated  "  permanent  sound  for  the 
oesophagus."  * 

The  difficulties  of  introducing  the  instrument  grow  proportion- 
ately with  the  increase  in  the  consecutive  dilatation  of  the  gullet 
or  of  the  possible  excrescences  and  pockets  of  the  constricting 
growth.  At  times  it  would  appear  that  in  cases  in  which  a  diver- 
ticulum had  also  formed  it  might  be  possible  to  pass  the  sound  be- 
yond the  pocket  and  into  the  stomach  by  giving  it  a  certain  direc- 
tion; thus  several  authors  give  niles  for  this  purpose.  In  my 
opinion,  if  the  obstruction  is  just  above  tlie  cardia,  this  is  entirely 
illusory.  ]!!«[one  of  the  sounds  which  we  are  able  to  introduce  into 
the  oesophagus  possesses  rigidity  enough  to  enable  us  to  give  its 
point  a  definite  direction  after  it  has  reached  the  level  of  the  lower 
portion  of  the  oesophagus.  One  can  easily  convince  himself  of  this 
on  a  corpse  or  a  suitably  suspended  preparation  in  which  the  stom- 
ach and  oesophagus  are  preserved  entire  and  in  continuity.  E'either 
have  I  been  able  to  discover  any  particular  advantage  in  a  special 
position  of  the  patient  according  to  the  supposed  site  of  the  dilata- 
tion. We  must  admit  that  in  an  actual  case  it  is  a  matter  of  luck 
whether  the  introduction  of  the  sound  is  successful  or  not.  How- 
ever, that  the  posture  of  the  patient  may  come  into  consideration 
during  the  passage  of  the  food  swallowed  is  shown  by  the  follow- 
ing very  excellent  example : 

On  the  19th  of  July  I  was  consulted  by  B.,  a  farmer  from  Stendal.  He 
had  been  examined  by  several  physicians  because  of  a  group  of  symptoms 
which  pointed  to  a  diverticulum  of  the  oesophagus.  By  some  his  condi- 
tion was  said  to  be  a  diverticulum,  while  others  considered  it  a  nervous 
spasm  of  the  gullet.  The  patient's  nutrition  and  general  condition  ap- 
peared little  changed.  He  could  attend  to  his  business  as  well  as  ever, 
but  he  felt  a  slight  loss  of  strength,  and  as  he  had  read  about  the  pernicious 
results  of  oesophageal  diverticula,  he  was  in  doubt  whether  or  not  to  give 
up  his  property,  retire,  make  all  arrangements  in  conformity  therewith, 
and  await  the  threatening  y?naZe.  The  difficulties  in  swallowing  had  late- 
ly increased  very  slowly  ;  subjectively  they  manifested  themselves  only  in 
occasional  regurgitation  of  the  food.     In  reference  to  this  the  patient  had 

*  Wiener  med.  Wochenschr,,  1887,  No.  43. 


TREATMENT  OP  STRICTURES   OP  CARDIA.  145 

observed  that  at  times  portions  of  "  regurgitated  "  food  had  been  eaten  not 
at  the  last,  but  at  a  previous  meal.  The  sound  was  caught  in  a  deeply  sit- 
uated sac  after  being  introduced  40  centimetres  [16  inches]  from  the  in- 
cisors. This  made  the  patient  cough,  when  he  brought  uj)  unchanged 
coffee  which  he  had  taken  three  hours  before.*  It  contained  no  free  acid- 
No  deglutition  murmurs  could  be  heard  with  the  patient  in  the  erect 
posture.  On  the  other  hand,  however,  when  he  lay  down,  a  second  sound 
could  be  heard  very  distinctly  twelve  seconds  after  swallowing.  This  was 
confirmed  by  frequent  repetition.  Thus  the  entrance  of  food  into  the 
stomach  was  not  entirely  prevented,  but,  as  the  sound  proved,  was  possible 
under  special  conditions.  In  spite  of  this,  even  on  a  second  trial,  I  was 
unable  to  pass  a  sound  into  the  stomach,  whether  the  patient  was  erect 
or  recumbent.  It  was  plainly  to  be  seen  that  in  this  case  conditions  were 
created  by  the  dorsal  decubitus  which  rendered  the  passage  of  the  swal- 
lowed mass  a  possibility.  We  can  therefore  assume  that  the  dilatation — 
for  with  this  we  had  to  deal,  without  any  doubt — was  situated  anteriorly, 
so  that  when  the  patient  lay  on  his  back  it  collapsed  to  a  certain  extent, 
and  thus  did  not  form  a  trap.  At  any  rate,  the  diverticulum  was  a 
small  one,  for,  after  the  patient  had  been  directed  to  drink  a  whole  glass- 
ful of  water,  the  deglutition  murmur  could  be  heard  when  he  was  stand- 
ing. This  proved  that  the  sacculation  was  now  filled,  and  that  it  neither 
caught  any  further  masses  which  were  swallowed  nor  prevented  their  en- 
trance into  the  stomach.  Thus  a  sufficient  degree  of  nutrition  was  still 
possible,  and  in  this  way  only  could  I  explain  the  relatively  good  condi- 
tion of  the  patient,  which  had  manifestly  been  the  reason  why  others  as- 
sumed the  presence  not  of  stricture  or  of  a  diverticular  formation,  but  of 
a  spastic  condition  of  the  oesophagus,  especially  if,  as  is  very  possible,  they 
could  occasionally  introduce  a  sound  into  the  stomach  without  any 
trouble.  It  is  to  be  regretted  that  circumstances  did  not  permit  a  subse- 
quent examination  of  the  patient ;  nevertheless,  the  facts  just  laid  before 
you  were  amply  sufficient  to  exclude  a  spastic  contracture  and  to  estab- 
lish the  diagnosis  of  a  diverticulum.  As  for  treatment,  I  advised  the 
patient  to  abstain  from  all  sounding  for  the  present,  for  if  the  sound  took 
a  false  direction  this  might  give  rise  to  unpleasant  signs  of  irritation,  per- 
haps to  mechanical  enlargement  of  the  diverticulum ;  further,  only  to 
permit  it  when  his  difliculties  had  become  more  marked,  especially  when 
the  feeling  of  obstruction  on  swallowing  appeared  ;  and,  finally,  to  assume 
a  recumbent  position  as  much  as  possible  when  eating. 

Especially  good  results  from  the  use  of  the  sound  are  met  with 
in  cases  of  cicatricial  strictures  if  the  patience  of  both  patient  and 
physician  holds  out,  and,  in  case  the  stricture  has  become  more  pa- 
tent, their  use  is  not  discontinued  too  soon.  Even  if  the  constriction 
seems  to  be  sufficiently  dilated  the  use  of  the  sounds  should  not  be 

*  In  a  case  of  Delia  Chiaje  (cited  by  Mackenzie)  coffee  was  regurgitated  as 
late  as  five  days  after  it  had  been  swallowed,  without  being  in  the  least 
changed. 


146  DISEASES  OP  THE  STOMACH. 

stopped  for  some  time,  for  the  contractile  tendency  of  cicatricial 

tissue  is  very  great  and  constantly  recurring. 

•  For  a  long-  time  after  the  campaign  of  1870  I  treated  a  yoimg  physi- 
cian who,  returning  to  camp  extremely  fatigued  one  day,  had  received  a 
burn  and  consecutive  stricture  of  the  oesophagus  by  attempting  to  drink 
from  a  canteen  apparently  filled  with  water.  The  vessel — whether  pur- 
posely or  not,  we  will  leave  unsettled — was  filled  with  pure  sulphuric 
acid !  He  could  only  spit  out  a  portion  of  the  first  hasty  swallow,  and 
thus  the  poor  fellow  not  only  received  a  severe  burn  of  the  oesophagus, 
but  also  had  to  suffer  from  a  consecutive  stricture.  In  this  patient  I 
could  follow  the  tendency  to  constantly  recurring  narrowing  of  the 
affected  spot  for  years. 

I  could  describe  similar  cases,  but  instead  sliall  simply  recall 
that  of  a  boy,  nine  years  of  age,  who,  in  spite  of  looking  very 
well,  had  a  stricture  after  swallowing  lye.  It  becomes  almost  im- 
passable every  few  months,  and  he  must  then  be  taken  to  the 
hospital.  Here  the  stenosis  is  soon  dilated,  only  to  recur  if  the 
treatment  is  neglected. 

J^ow  that  the  true  poisons  are  used  more  frequently  for  purposes 
of  suicide,  we  do  not  have  the  opportunities  which  we  formerly  had 
to  study  these  cicatricial  strictures  and  their  course  when  it  was  still 
the  fashion  for  maidservants  to  poison  themselves  with  "oleum" 
(impure  sulphuric  acid)  ;  for,  queer  as  it  may  seem,  fashion  has  a 
decided  influence  even  upon  this  melancholy  procedure  !  I  regret 
that  I  do  not  possess  any  statistical  records  of  that  period,  so  that  I 
can  only  say  from  my  general  impression,  in  accordance  with  the 
views  of  other  authors,  that  cicatricial  strictures  offer  a  favorable 
prognosis  unless  they  reach  a  certain  degree  of  constriction  ;  but  as 
soon  as  we  have  to  deal  with  advanced  stages,  sounding  leaves  us  in 
the  lurch  exactly  as  it  does  in  cancerous  constrictions.  The  latter 
especially  always  offer  unfavorable  prospects.  We  may  indeed  suc- 
ceed in  making  the  canal  more  patent  for  a  time,  but  we  can  not 
permanently  contend  with  the  progressive  new  growth.  Again,  we 
must  not  be  surprised  or  deceive  ourselves  with  false  hopes,  if, 
especially  toward  the  end  of  hfe,  the  stricture  suddenly  seems  to 
become  more  patent  or  to  have  disappeared  entirely.  This  is  a  re- 
sult of  ulceration,  and  is  always  to  be  regarded  as  a  bad  omen. 

For  most  strictures  nothing  remains  but  gastrostomy,  the  estab- 
lishment  of  a  gastric  fistula,   first  proposed  by   Egeberg  in  1837 


GASTROSTOMY.  147 

and  performed  by  Sedillot  in  1849.  The  tortures  whicli  the  pa- 
tients suffer  from  their  disease,  the  slow  starvation  which  is 
their  lot,  are  indeed  so  frightful  that  we  must  attempt  relief 
even  if  we  know  it  will  only  be  transient.  It  is  to  be  regretted 
that  as  yet  the  operation  is  performed  too  late  in  most  cases. 
The  patients  are  very  slow  to  consent  to  a  procedure  about  which, 
even  though  very  unjustly,  there  still  hangs  a  nimbus  of  its  being  a 
wonderful  operation.  They  only  submit  from  extreme  necessity, 
and  thus  the  best  time,  that  of  a  relatively  good  general  condition, 
passes  by.  It  is  true  that  recently  there  has  been  a  decided  prog- 
ress in  this  direction,  and  consequently  the  results  of  the  operation 
have  progressively  become  more  favorable.  In  1864  Mackenzie 
collected  67  cases  of  gastrostomy  in  carcinoma  of  the  oesophagus, 
12  of  cicatricial  stricture,  and  2  of  syphilitic  stricture,  and  found 
that  the  longest  duration  of  life  amounted  to  from  5^  to  7^  months. 
Then,  in  1885,  Zesas  *  collected  129  cases  of  cancer,  31  of  cicatricial 
stricture,  and  2  cases  of  syphilis,  and  estimated  16*2  per  cent  of 
cures  (?)  in  the  first,  55  per  cent  of  cures  in  the  cicatricial  strictures, 
and  among  the  deaths,  17*2  per  cent  who  survived  the  operation  for 
twelve  months.  If  we  select  only  those  operations  which  have  been 
performed  since  the  inauguration  of  antisepsis  (131),  we  get  19*5 
per  cent  for  cancer  and  68-7  per  cent  for  cicatricial  stenosis.  Un- 
fortunately it  is  a  matter  of  surmise  as  to  what  is  meant  by  19*5 
per  cent  cured,  and,  according  to  my  own  experience,  it  is  not  diffi- 
cult to  understand  why  most  surgeons  are  by  no  means  anxious 
to  undertake  an  operation  which  does  not  save  life. 

Gastrostomy  to-day  is  in  itself  so  free  of  danger  that  it  is  indi- 
cated in  every  case  as  soon  as  the  diagnosis  of  a  nondilatable  stric- 
ture of  the  cardia,  with  or  without  consecutive  dilatation,  is  estab- 
lished, l^othing  else  can  save  the  patient  from  the  starvation  which 
threatens  him.  The  chances  for  success  naturally  depend  upon  the 
character  of  the  constriction,  and  the  earlier  the  operation  is  under- 
taken and  the  less  the  general  condition  of  the  patient  is  depressed 
the  better  are  the  prospects.  That  this  operation  can  not  save  life 
need  scarcely  be  mentioned.     At  any  rate,  if  no  abnormal  intercur- 

■•^  G.  Zesas..    Die  Gastrostomie  und  ihre  Resultate.    Aruh.-  f.  klinische  Chirurgie, 
Bd.  xxxii,  S.  188. 


148  DISEASES  OP  THE  STOMACH. 

rent  attacks  appear,  life  is  prolonged,  and  death  in  cases  of  carci- 
noma is  due  to  the  more  or  less  rapid  course  of  cancerous  intoxica- 
tion and  not  to  starvation.  Even  the  psychical  influence  of  the 
operation  on  the  patients,  the  advantages  of  which  can  readily  he 
understood,  is  not  to  be  underestimated,  and  the  reproach  made  by 
a  patient  to  Prof,  Kocher,  that  "  he  had  unnecessarily  made  a  hole 
in  his  stomach,"  may  well  be  regarded  as  exceptional.  Among  five 
patients  to  whom  I  proposed  the  operation,  only  one  refused  to  un- 
dergo it,  and  he  was  a  Russian  general,  who  preferred  death  in  St. 
Petersburg  to  an  operation  in  Berlin. 

For  the  technique  of  the  operation  I  would  refer  to  the  text- 
books on  surgery.*  I  shall  only  make  one  suggestion,  to  place  the 
opening  of  the  fistula  in  the  stomach  as  close  to  the  pylorus  as  pos- 
sible, so  that  with  a  soft-rubber  tube  the  food  may  be  introduced 
directly  into  the  duodenum,  the  pylorus  serving,  if  possible,  as  a 
valve  ;  for,  as  I  shall  show  later  on,  the  peptic  and  motor  powers  of 
the  stomach  are  very  much  lessened  in  all  these  cases,  the  digestion 
being  carried  on  entirely  by  the  intestines.  Hence  it  is  inexpedient 
to  load  the  stomach  with  food  which  will  only  be  decomposed  there, 
or  will  be  rejected,  unless  it  is  promptly  passed  on  through  the 
pylorus. 

However,  it  is  to  be  regretted  that  the  dilatation  of  the  oesopha- 
gus is  not  removed  by  gastrostomy.  The  introduction  of  food  into 
the  body  is  naturally  no  longer  prevented,  but  above  the  stricture 
there  "remains  a  breeding  place  for  all  kinds  of  putrefactive  germs. 
The  patients  are  constantly  swallowing  saliva ;  although  after  the 
formation  of  the  fistula  they  complain  very  little  or  not  at  all  about 
hunger,  they  are  frequently  troubled  with  severe  thirst.  We  may 
permit  them  to  swallow  small  pieces  of  ice  and  even  to  drink  some 
wine.  Later  the  dilated  gullet  becomes  filled  with  fluid  contents  which 
at  once  putrefy,  a  strong  fetid  odor  emanates  from  the  mouth,  and 
either  spontaneously  or  through  the  stomach  tube  the  patients  force 
up  a  fluid  with  the  odor  of  decaying  meat,  which  on  microscopic 
examination  proves  to  be  almost  a  pure  culture  of  putrefaction 


*  [An  excellent  paper  on  the  various  methods  and  indications  for  gastrostomy 
and  other  methods  of  operation  in  stricture  of  the  oesophagus,  is  that  of  Willy- 
Meyer.    Amer.  Journal  of  Medical  Sciences,  October,  1894,  p.  400.— Ed.J 


FEEDING  IN  CARDIAC  STRICTURES.  149 

cocci.  Under  sucli  circumstances  we  must  wash  out  the  saccula- 
tion as  we  do  a  stomach,  and  for  this  purpose  we  maj  use  disinfect- 
ing fluids  (sahcylic  acid,  thymol,  resorcin,  borax,  etc.),  or  we  may 
introduce  salicylic  acid  or  boric  acid  in  substance.  I  have  also  given 
strong  cognac  in  teaspoonful  doses  in  order  to  get  the  disinfecting 
action  of  the  alcohol. 

Finally,  the  question  of  feeding  must  be  considered. 

At  an  early  period  the  patients'  own  experience  teaches  them  to 
take  gruels  and  fluid  nourishment  instead  of  solid  food.  Since  the 
functions  of  the  stomach  themselves  have  not  suffered,  as  long  as 
the  lesion  is  not  a  cancerous  growth — about  which  more  hereafter — 
we  must  only  consider  the  digestibility  of  the  food  in  so  far  that 
we  do  not  allow  indigestible  articles  of  diet  to  persons  who  are  more 
or  less  debilitated,  but  that  we  must  try  to  give  as  much  nourish- 
ment as  possible  in  the  most  compact  form.  Besides  pure  milk, 
the  paps  and  broths  known  in  every  kitchen,  raw  and  soft-boiled 
eggs,  thick  gruels  of  wheat,  oatmeal,  and  barley  flour,  we  may  also 
use  the  so-called  leguminous  flours  *  (containing  varying  quantities 
of  nitrogen)  which  are  now  sold  in  various  forms,  as  well  as  beef 
peptone,  peptone  chocolate,  and  Mosquera's  beef  meal.  We  can 
also  make  a  palatable  meat  broth  of  an  almost  sirupy  consistency  by 
taking  raw  beef  which  has  been  chopped  up  very  fine,  stirring  it 
with  an  egg,  and  adding  some  pepper  and  salt.  Koumiss  is  readily 
taken  by  some  for  a  long  time  on  account  of  its  acid  taste,  while  it 
soon  becomes  repugnant  to  others.  Moreover,  in  this  respect  it 
presents  no  exceptions  to  the  rest  of  the  artificial  food  preparations, 
all  of  which  have  the  same  disadvantage  of  always  sooner  or  later 
becoming  unpleasant  or  even  disgusting.  ISTature  does  not  permit 
herself  to  be  mocked  at ;  and  if,  for  instance,  she  provides  albumi- 
noids in  various  forms  in  the  common  foods,  and  not  pure  peptones, 
we  can  not  substitute  the  latter  for  the  former  without  being  pun- 
ished in  regard  to  the  taste  and  its  results.  However  much  the 
praises  of  the  excellent  flavor  of  these  preparations  may  be  sung, 
they  all  have  the  fault  just  spoken  of,  and  a  substitute  for  ordinary 
food  with  a  good  taste  that  is  always  pleasant  and  agreeable  is  still 
to  be  found. 

*  [Thompson's  Dietetics,  1896,  p.  145.— Ed.] 


150  DISEASES  OP  THE  STOMACH. 

The  amylaceous  flours,  sucli  as  tapioca,  arrowroot,  and  sago,  can 
not  be  recommended,  first,  because  they  are  very  poor  in  nitrogen — 
in  fact  in  nourishment  altogether — and,  secondly,  because  the  diastatic 
action  of  the  saliva  is  needed  for  their  conversion ;  but  this  reaches 
the  stomach  in  a  smaller  amount  than  usual,  since  it  is  produced  in 
a  smaller  quantity  inasmuch  as  the  stimulus  for  a  more  marked  se- 
cretion of  saliva,  the  mastication  of  solid  food,  is  practically  entirely 
abolished. 

Yery  soon,  however,  there  arises  the  necessity  of  supplementing 
the  deficient  nourishment  by  the  mouth  by  means  of  the  administra- 
tion of  food  per  rectum.  Although  rectal  alimentation  dates  back 
to  the  earliest  times  in  medicine,  yet  great  credit  is  due  to  Kuss- 
maul,  Leube,  Rosenthal,  and  others,  for  having  placed  it  on  a  scien- 
tific basis.  The  necessary  confidence  in  this  method  of  feeding 
was  supplied  by  the  proof  that  we  could  maintain  the  nitrogen 
equilibrium  in  animals  by  rectal  injections  of  peptone  and  peptone- 
like bodies ;  but  it  was  an  error  to  suppose  that  we  must  use  pep- 
tonized albumen  for  this  purpose.  In  a  special  series  of  experi- 
ments *  I  proved  that  the  injection  of  common  emulsified  white  of 
Qgg  serves  the  same  purpose,  and  that  the  mucous  membrane  of  the 
lower  portion  of  the  intestine  manifestly  possesses  the  power  of  ab- 
sorbing not  only  peptones  but  unchanged  white  of  egg  as  well,  and 
to  render  it  useful  in  the  metabohsm  of  the  body.  In  estimating 
the  value  of  peptones  in  rectal  feeding,  the  conditions  in  alimenta- 
tion by  the  intestine  and  by  the  stomach  have  been  falsely  placed  on 
the  same  basis,  although  they  differ  fundamentally,  since  in  the 
former  case  the  mucous  membrane  is  healthy,  and  in  the  latter  it  is 
diseased  and  its  functions  more  or  less  impaired.  Hence  in  the  one 
case  the  indication  is  to  diminish  as  much  as  possible  the  work  of  the 
organ  so  far  as  it  concerns  the  chemical  changes  of  the  food ;  in 
the  other,  however — i.  e.,  in  rectal  alimentation — there  is  a  healthy 
mucous  membrane  capable  of  performing  its  functions,  and  it  is  not 
necessary  to  do  a  portion  of  its  work  outside  of  the  body.  We  will 
never  be  placed  in  the  position  to  employ  nutrient  enemata  when 
the  intestinal  mucous  membrane  is  unhealthy,  because  in  the  vast 


*  0.  A.  Ewald.     Ueber  die  Ernahrung  mit  Pepton-  und  Eierklystieren.    Zeit- 
schr.  f.  klin.  Med.,  Bd.  xii,  Hefte  5  u.  6. 


RECTAL   PEEDINa.  151 

majority  of  such  cases  tlie  stomacli  is  capable  of  performing  its 
duties.  However,  should  both  stomach  and  rectum  be  diseased  in 
the  same  patient— and  this  is  one  of  the  greatest  rarities—and  should 
indeed  the  question  of  artificial  nutrition  arise,  feeding  by  the  mouth 
would  always  offer  the  better  chances. 

I  order  the  nutrient  enemata  to  be  prepared  as  follows :  A  tea- 
spoonful  of  wheat  flour  is  cooked  with  haK  a  cupful  of  a  20-per- 
cent solution  of  glucose  and  a  wineglassful  of  claret  added.     Two 
or  three  eggs  are  beaten  up  smooth  with  a  tablespoonful  of  water 
and  slowly  stirred  in  with  this  after  it  has  cooled  sufficiently  to  pre- 
vent the  coagulation  of  the  albumen.     The  entire  quantity  should 
not  measure  more  than  i  litre  [^  pint].     In  hospital  practice  or  with 
the  poor,  three  to  five  eggs,  with  about  150  c.  c.  [f  3  v]  of  a  15-  or 
20-per-cent  solution  of  glucose,  may  either  be  injected  or  allowed  to 
flow  in.     If  necessary  to  make  the  mass  thicker,  we  can  add  starch 
solution  or  mucilage ;  or  a  few  drops  of  tincture  of  opium  to  lessen 
any  possible  irritation.     According  to  Huber,*  w^ho  repeated  and 
confirmed  my  experiments,  the  efficacy  of  the  egg  enema  may  be 
increased  by  the  addition  of  some  common  salt,  in  the  proportion  of 
about  one  gramme  [gr.  xv]  to  each  egg.     A  cleansing  enema  of 
250  c.  c.  [f  5  viij]  of  lukewarm  water  or  of  salt  solution  must  always 
precede  the  nutrient  enem?.,  and  we  must  wait  till  the  passages — 
often  frequent — are  over,  otherwise  it  may  happen  that  the  nutrient 
enema  will  be  immediately  ejected.     Such  injections  may  either  be 
given  two  or  three  times  a  day  or  the  quantity  divided  into  smaller 
enemata.     It  is  well  to  bear  in  mind  that  during  such  a  course  the 
faeces  may  readily  assume  a  ribbonlike  form  and  a  light  yellow  color. 
Such  enemata  may  be  given  for  a  long  time  without  the  intestine 
reacting  and  causing  their  rapid  expulsion.     We  must  only  use  the 
precaution  of  allowing  the  fluid  to  flow  in  very  slowly  through  a 
soft  tube  introduced  as  high  as  possible  into  the  bowel,  the  best 
being  a  large  soft-rubber  tube,  about  the  size  of  a  finger  or  an 
oesophageal  tube,  with  an  eye  at  the  lower  end  and  numerous  lateral 
openings.     The  irrigator  is  held   about   two  feet  above  the  anal 
orifice  of  the  patient,  or  the  piston  of  the  syringe  or  the  rubber 


*  A.  Huber.    Deutsch.  ArcLiv  fiir  klin.  Med.,  Bd.  xlvii. 
11 


152  DISEASES  OF  THE  STOMACH. 

bulb  is  worked  gradually.  For  some  time  after,  the  patient  re- 
mains either  in  the  dorsal  or  left  lateral  position.  In  case  of 
marked  irritability  of  the  intestines  a  few  drops  of  tincture  of 
opium  may  be  added  to  the  enema  at  first ;  but  this  soon  becomes 
superfluous  and  is  rarely  necessary  for  any  length  of  time.  I  have 
never  seen  more  than  a  transient  benefit  derived  froni  the  rubber 
tampons  (similar  to  the  colpeurynter)  devised  for  keeping  back 
the  injected  fluid.  They  are  pushed  into  the  bowel  beyond  the 
sphincter,  and  are  then  dilated  with  air  or  water.  They  can  not 
be  passed  beyond  the  third  sphincter,  and  after  they  have  resisted 
the  intestinal  peristalsis  several  times  they  lose  their  efficacy ;  also, 
owing  to  the  irritation  which  they  produce  on  the  mucous  mem- 
brane, they  render  the  intestine  still  more  sensitive  and  intolerant  to 
the  injections  than  would  be  the  case  without  them,* 

Finally,  the  nourishment  after  the  formation  of  a  gastric  fistula 
is  to  be  considered.  The  kind  and  quantity  of  food  which  will  be 
borne  under  such  circumstances  will  depend  primarily  upon  the 
nature  of  the  original  disease.  The  celebrated  Canadian,  Alexis  St. 
Martin,  seems  to  have  consumed  very  nourishing  food  without  any 
detriment.  I  have  myself  seen  the  boy  with  the  cicatricial  oesopha- 
geal stricture  who  was  operated  on  by  Trendelenburg  enjoy  bread 
and  butter,  together  with  meat,  potatoes,  and  vegetables,  which  he 
introduced  into  the  fistula.f  The  patient  operated  on  by  Yerneuil, 
and  the  case  described  above  (p,  138),  also  had  an  ample  bill  of  fare 
from  which  to  choose. :{:  However,  these  are  all  cases  of  a  non- 
cancerous nature  with  relatively  good  general  condition  in  which, 
no  doubt,  at  flrst  a  nutrient  solution  as  unirritating  and  simple  as 
possible  was  poured  into  the  fistula  and  a  mixed  diet  given  only 
later  on.  The  exact  investigations  made  by  me  *  have  shown  that 
the  digestive  functions  of  the  stomach  suffer  very  little  in  such 
cases.     In  cases  where  gastrostomy  is  performed  for  carcinoma  of 

*  [See  Thompson's  Dietetics,  1896,  p.  375,  for  an  excellent  discussion  on  rectal 
fe-iding.— Ed.] 

f  He  chewed  the  food,  and  then  pressed  it  from  his  mouth  into  his  stomach 
through  a  large  rubber  tube. 

X  Cited  by  Ch.  Richet.  Du  sue  gastrique  chez  I'homme  et  les  animaux.  Paris, 
1878,  p.  88. 

*  Ewald.    Zeitschr.  fiir  klin.  Med.,  Bd.  xx,  Hefte  4-6. 


FEEDING  AFTER  GASTROSTOMY.  153 

the  cardia  (whetlier  situated  on  its  oesopliageal  or  gastric  side),  what 
are  tlie  changes  in  the  secretion  of  the  gastric  juice  and  in  the 
digestive  functions  of  the  stomach  ?  It  is  self-evident  that  the 
feeding  must  vary  considerably  according  to  the  answer  to  this 
question  ;  but  it  is  also  clear  that,  partly  at  least,  this  will  coincide 
with  the  usual  changes  in  the  digestive  functions  in  gastric  cancer. 
I  shall  consider  these  relations  in  their  proper  connection  while 
discussing  carcinoma  of  the  stomach ;  but  for  our  present  purpose 
I  shall  anticipate  and  say  that  in  all  cases  which  were  operated 
upon  I  have  never  found  any  secretion  of  hydrochloric  acid  or  of 
pepsin.  In  several  of  those  who  died  a  short  time  after  the  opera- 
tion this  might  be  ascribed  to  the  weakness  of  the  patients  ;  but 
the  previously  mentioned  case  of  the  woman  with  the  numerous 
cancerous  metastases  and  the  carcinomatous  stricture  of  the  oesopha- 
gus is  more  important.  Here  the  stomach  contents  flowing  from 
the  fistula  were  repeatedly  examined,  the  last  time  four  months 
subsequent  to  the  operation,  after  the  patient  had  introduced  gruel, 
or  gruel  with  egg  and  zwieback,  one,  one  and  a  half,  and  two 
hours  previously.  The  fluid  which  flowed  out  was  invariably 
only  slightly  changed,  containing  a  little  mucus,  of  neutral  reac- 
tion, without  peptone,  and  its  filtrate  had  no  digestive  action  either 
on  the  addition  of  hydrochloric  acid  or  of  pepsin.  The  secretion  of 
the  glands,  therefore,  had  ceased  completely  and  permanently.  I 
wish  to  state  that  in  the  other  cases,  even  before  the  operation, 
while  it  was  still  possible  to  introduce  a  sound  into  the  stomach, 
I  found  the  stomach  contents  to  be  likewise  free  from  the  peptic 
secretion.  The  same  result — i.  e.,  the  absence  of  hydrochloric  acid 
— was  found  by  JS^eschaieff  *  in  105  examinations  on  four  patients 
with  carcinomatous  stricture  of  the  oesophagus.  Reports  like  that 
of  Eiegel,  f  who  found  "  the  time  of  digestion  and  the  amount  of 
HCl  normal "  in  two  cases  (the  site  of  the  carcinoma  is  not  ac- 
curately given  and  the  stricture  was  undoubtedly  still  patent),  and 
a  similar  case  of  Boas,  must  be  considered  rare  exceptions,  and  in 
which  a  cardiac  carcinoma  did  not  exist. 

*  Lancet,  June  4,  1887. 

f  P.  Riegel.     Beitrage  zur  Diagnostik  der  Magenkrankheiten.    Zeitschr.  f.  klin. 
Med.,  Bd.  xii,  8.  434 


154  DISEASES  OP  THE  STOMACH. 

Under  the  circumstances  wMcli  I  have  described  it  is  evident 
that  we  must  refrain  as  far  as  possible  from  giving  food  which  in 
any  way  demands  more  of  the  stomach  than  that  which  can  be  ab- 
sorbed and  passed  on  into  the  intestine  as  quickly  as  possible.  This, 
therefore,  is  where  the  various  peptone  preparations  are  indicated. 
They  must  be  supplemented  with  carbohydrates  and  fats.  In  order 
to  compensate  for  the  absence  of  the  diastatic  action  of  the  saliva 
we  give  its  product,  glucose,  or  we  allow  the  patients  to  mix  the 
food  with  saliva  by  mastication  and  then  to  transfer  it  by  means  of 
a  tube  directly  from  the  mouth  to  the  stomach.  In  such  cases  the 
nutrition  depends  entirely  on  the  preservation  of  the  absorptive  and 
motor  functions  of  the  stomach,  and  therefore  the  "  diet "  of  such 
patients  could  be  made  typically  simple  and  restricted  to  a  solu- 
tion of  peptone  and  glucose,  together  with  some  fat,  were  it  not 
that  we  must  take  account  of  their  desire  to  masticate  and  taste 
the  food,  and  thus  satisfy  the  sensation  of  hunger  as  well  as  their 
aesthetic  sensations. 


CHAPTEE   lY. 

THE  ge:s^eeal  relations  of  the  stomach  to  the  organism. IN- 

FLAjVIMATION    of    the    stomach. GASTRITIS    GLANDULARIS    ACUTA, 

IDIOPATHICA     ET      SYMPATHICA. GASTRITIS     PHLEGMONOSA    PURU- 

LENTA. GASTRITIS    TOXICA. 

Having  discussed  tlie  obstructions  wliicli  tlie  food  may  encounter 
in  reacliing  the  stomach,  our  next  consideration  is  acute  and  chronic 
gasti'itis,  bj  far  the  most  frequent  of  the  diseases  to  wliich  the 
stomach  is  subject. 

Before  entering  upon  this  topic  I  wish  to  preface  a  few  re- 
marks of  a  general  nature  upon  the  mutual  relations  of  the  stomach, 
intestines,  and  liver,  and  the  influence  of  gastric  disorders  upon  the 
general  metabolism. 

The  Mutual  Eelations  of  the  Stomach,  Liver,  and  Intestines. — In 
his  lectures  on  general  pathology  Cohnheim  very  properly  says  that 
it  is  a  characteristic  feature  of  diseases  of  the  stomach  that  one  and 
the  same  factor  tends  to  disturb  the  phenomena  of  digestion  in  so 
many  different  ways.  In  fact,  the  absorption,  secretion,  and  move- 
ments of  the  stomach  have  such  a  close  and  interchangeable  con- 
nection that  under  all  circumstances  injury  to  the  one  also  involves 
the  others.  Every  alteration  of  the  secretion  (e.  g.,  following  an 
acute  gastritis)  changes  the  normal  course  of  those  functions  known 
to-day  by  the  designation  of  the  chemismus.  But  unalterably  con- 
nected with  every  disturbance  of  the  chemismus  we  ftnd  also  changes 
in  absorption  and  peristalsis  ;  for,  should  the  secretion  of  acid  and 
pepsin  be  insufficient,  there  is  not  only  a  retardation  in  the  forma- 
tion of  absorbable  nitrogenous  substances,  but  also  the  degree  of 
acidity  necessary  for  efficient  peristalsis  and  the  transfer  of  the 
chyme  into  the  intestines  is  attained  either  very  late  or  not  at  all. 

The  ingesta  stagnate  and   undergo   abnormal   decomposition,  the 

155 


156  DISEASES  OP  THE  STOMACH. 

products  of  wliicli  not  only  further  irritate  tlie  gastric  mucosa,  but 
also  alter  the  conditions  of  absorption  and  exert  a  paralyzing  influ- 
ence upon  the  muscularis,  either  by  their  absorption  into  the  vessels 
or  by  the  mechanical  distention  of  the  organ  with  gases.  Further- 
more, deficient  muscular  action  has  a  depressing  effect  on  the  inten- 
sity of  absorption ;  insufficient  absorption  leads  to  stagnation  in  the 
venous  system,  and  this  in  turn  to  impairment  of  the  secretion. 
Thus  a  vicious  circle  is  formed,  and  one  can  easily  appreciate  that 
there  is  no  difference  at  which  part  of  the  chain  you  begin ;  for 
unless  the  deficiency  of  one  function  is  compensated  by  the  in- 
creased action  of  the  others  all  the  resulting  phenomena  will  also  be 
developed,  whether  the  first  change  was  in  the  secretion,  motion,  or 
absorption.  If  we  succeed  in  breaking  this  endless  chain  of  dele- 
terious infiuences  at  one  place,  we  effect  a  cure  of  the  remaining 
functions — that  is,  provided  the  primary  cause  no  longer  acts.  This 
gives  a  partial  explanation  of  the  fact  that  so  many  cases  of  what 
had  been  up  to  the  present  time  designated  catarrh  were  cured  by 
the  most  varied  modes  of  treatment. 

I  believe  that  such  regulation  frequently  occurs  without  our  aid 
and  without  therapeutic  interference,  and  it  is  only  by  such  a  com- 
pensation that  the  manifold  direct  and  indirect  disturbances  to  which 
this  viscus  is  constantly  subjected  are  equalized.  Only  on  the  dis- 
appearance of  this  compensation  do  we  encounter  what  has  been 
collectively  designated  dyspepsia.  As  the  result  of  this  regulation 
a  certain  amount  of  the  reserve  force  is  called  into  play,  which,  as 
in  valvular  disorders  of  the  heart,  brings  about  a  compensation  for 
a  longer  or  shorter  period,  as  the  result  of  which  one  function  of 
the  stomach  may  be  replaced  by  the  increased  activity  of  another. 
How  else  could  we  explain  the  fact  that  persons  with  a  complete 
absence  of  hydrochloric-acid  secretion  may  live  for  years  without 
marked  dyspeptic  difficulties  ?  or  that  a  marked  dilatation  and 
atony  of  the  stomach  may  exist  for  a  long  time  without  causing  any 
special  disturbance  ?  On  the  one  hand,  there  is  an  increased  peri- 
stalsis of  the  stomach  by  which  the  ingesta  are  transferred  to  the 
intestines  before  they  can  decompose  or  before  any  other  disturb- 
ance may  occur ;  on  the  other  hand,  there  is  a  greater  activity  in 
the  chemical  function  of  the  stomach  which  counteracts  any  f ermen- 


MUTUAL   RELATIONS   OP   STOMACH.  157 

tation  in  the  food  wliicli  may  be  unduly  retained  in  the  stomach  ;  in 
these  ways  a  compensation  may  be  estabhshed.  There  is  thus  be- 
yond any  doubt  a  vicarious,  regulating  mechanism. 

But  it  will  not  suffice  to  simply  call  special  attention  to  the  indi- 
vidual manifestations  of  the  stomach's  functions,  however  obvious 
and  positive  the  fact  may  be.  A  thorough  comprehension  of  the 
morbid  processes  of  the  stomach  and  of  the  manifestations  of  the 
disturbance  of  gastric  digestion  is  not  to  he  obtained  without  a  con- 
sideration of  the  relations  existing  between  the  stomachy  the  intes- 
tines^ and  the  liver  /  for  every  disease  of  the  stomach  aifects  the 
intestines  and  liver,  and,  vice  versa,  every  disorder  of  the  latter  is 
reflected  upon  the  former.  Whether  it  be  that  the  stomach  con- 
tents are  rendered  abnormally  acid  from  the  presence  of  inorganic 
or  organic  acids,  or  because  they  contain  much  undigested  food 
mixed  with  mucus,  such  chyme  will  act  on  the  mtestines  as  an 
irritating  foreign  body  until  the  specific  intestinal  secretions,  bile, 
pancreatic  juice,  and  the  succus  entericus  succeed  in  quelling  this 
disturbance — i.  e.,  by  establishing  normal  digestion  and  absorption 
in  these  crude  masses.  Furthermore,  the  uj^per  portion  of  the 
duodenum  is  especially  involved,  and  hence  the  functions  of  the 
liver  are  disturbed  in  a  twofold  way  :  first,  purely  mechanically,  by 
swelling  the  orifice  of  the  common  bile  duct  (this  simply  causes  a 
retardation  in  the  flow  of  bile,  but  no  true  jaundice) ;  secondly,  by 
contaminating  the  blood  in  the  portal  vein  with  the  products  of 
incomplete  digestion,  which  slows  the  hepatic  circulation  and  in 
turn  retards  the  secretion  of  bile.  Lauder  Brunton  *  has  shown 
that  the  rapidity  of  the  circulation  in  the  excised  hver  depends 
very  markedly  upon  the  composition  of  the  blood  injected  into  its 
vessels.  Retardation  of  the  hepatic  circulation  necessitates  a  slowing 
of  the  biliary  secretion,  and,  since  the  bile  is  antifermentative  and 
digests  fats,  the  intestinal  digestion  is  doubly  affected. 

A  similar  course  of  events  occurs  when  the  liver  or  intestine  is 
the  viscus  primarily  involved,  with  the  exception  that  the  subse- 
quent course  of  the  process,  so  far  as  the  stomach  is  concerned,  is 
somewhat  different.     It  is  not  so  much  the  fact  that  the  intestines 

*  T.  Lauder  Brunton.  On  Disorders  of  Digestion,  their  Consequences  and 
Treatment.     London,  1886,  p.  25. 


158  DISEASES  OF  THE  STOMACH. 

are  full  and  offer  a  certain  resistance  to  the  expulsion  of  tlie  chyme, 
or  even  force  the  intestinal  contents  back  into  the  stomach ;  it  is 
not  the  reaction  which  each  retarded  peristaltic  wave  in  the  intes- 
tines exerts  on  the  peristalsis  of  the  stomach ;  but  it  is  rather  the 
obstruction  which  is  caused  in  the  entire  portal  circulation,  pro- 
ducing a  venous  stasis  in  all  the  radicles  of  this  extensive  venous 
system,  the  injurious  effects  of  which  are  manifested  even  in  the 
stomach.  A  venous  congestion  of  this  viscus  is  the  result,  which, 
as  we  have  already  seen,  sympathetically  affects  all  its  functions 
by  the  slowing  of  the  secretion  which  is  associated  therewith. 
Thus,  to  a  certain  extent,  in  every  case  of  dyspepsia,  there  are  two 
endless  circles — the  smaller  in  the  stomach,  the  larger  in  that  viscus 
and  also  the  intestines  and  liver — in  other  words,  the  entire  portal 
system. 

But  the  disturbance  of  the  hepatic  circulation  has  still  another 
significance.  The  function  of  the  liver  is  not  alone  to  secrete  bile, 
but,  being  interposed  between  the  portal  system  and  the  right  side 
of  the  heart,  it  also  forms  a  kind  of  trap  which  arrests  all  toxic  sub- 
stances absorbed  from  the  intestines ;  these  it  either  retains  and  only 
gradually  gives  up  in  small  quantities  to  the  circulating  blood,  or  it 
decomposes  these  substances  or  returns  them  to  the  intestines  by 
means  of  the  bile.  We  know  that  this  peculiarity  of  the  liver  ac- 
counts for  the  comparatively  harmless  action  of  snake  poison  or 
curare  when  taken  by  the  mouth.  "We  also  know  that  this  is  true 
of  nicotine,  and  must  also  assume  it  in  reference  to  the  toxic  pro23- 
erties  of  peptone.*  For  if  this  feature  of  the  latter's  action  is  not 
generally  manifested,  as  is  actually  the  case,  it  is  because  the  pep- 
tone has  been  reconverted  into  albumen  while  still  in  the  intestinal 
wall,  or  because  it  enters  the  general  circulation  in  such  minute 
quantities  or  so  slowly  that  it  remains  innocuous,  having  been  stored 
up  in  the  liver  or  converted  into  other  products.  Many  facts,  espe- 
cially the  presence  of  peptone  in  the  portal  blood,  indicate  the  oc- 
currence of  such  a  draining  action  of  the  liver,  which  fails  as  soon 
as  the  functions  of  the  viscus  are  disturbed.  This  applies  to  normal 
digestion.     This  process  is  even  more  marked  with  the  products  of 

*  Vide  Ewald.     Klinik,  etc.,  I.  Theil,  3te  Auflage,  p.  102. 


MUTUAL  RELATIONS  OP  STOMACH.  159 

imperfect  gastric  and  intestinal  digestion — i.  e.,  ptomaines,  those 
substances  generated  by  putrefaction  wliicli  possess  alkaloidal  prop- 
erties. Under  normal  conditions  these  have  no  effect  on  the  gen- 
eral system;  this  may  be  due  to  a  selective  action  of  the  intes- 
tinal epithelium  which  prevents  their  absorption,  or  they  may  be 
filtered  out  by  the  liver  as  described  above,  or  the  quantity  absorbed 
may  be  too  minute  to  have  any  toxic  effect. 

All  this  may  be  changed,  even  after  an  excessive  meal,  when 
the  amount  of  peptone  ^absorbed  is  suddenly  increased.  Apathy, 
dullness,  and  a  slight  drowsiness  are  the  result,  which  we  attempt  to 
counteract  by  the  use  of  stimulants  (coffee,  strong  liqueurs,  etc.). 
Such  products  are  formed  in  much  larger  quantities  as  soon  as, 
from  any  cause  whatever,  the  intestinal  digestion  has  become  inade- 
quate. Then  either  the  normal  impermeabihty  becomes  impaired 
or  the  action  of  the  liver  is  inadequate,  or  both  may  be  combined ; 
so  that,  whatever  may  be  the  final  cause,  the  toxic  substances  are 
taken  up  into  the  blood  and  give  rise  to  more  or  less  severe  symp- 
toms of  poisoning — autointoxication.*  In  the  mild  cases,  which 
happily  form  the  majority,  there  are  only  vague  cerebral  symptoms — 
fatigue,  languor,  mental  dullness,  and  headache — especially  in  the  oc- 
ciput. In  severer  cases  the  cardiac  action  is  sympathetically  affected  ; 
palpitation,  or  an  intermittent  or  irregular  pulse,  and,  finally,  even 
marked  symptoms  of  poisoning  may  appear,  possibly  as  the  result 
of  the  simultaneous  absorption  of  the  gases  of  putrefaction,  a  good 
example  of  which  is  the  well-knoMru  case  recorded  by  Senator.f 
Kulneff  X  was  able  to  directly  demonstrate  the  presence  of  a  toxine 
in  the  stomach  contents  of  two  cases  of  dilatation  of  the  stomach 
and  one  of  gastric  cancer. 

It  thus  becomes  evident  that  only  in  very  few  cases  can  we  speak 
of  disturbances  of  the  digestion  of  the  stomach  which  are  limited  to 
thit  viscus,  and  then  only  in  those  cases  in  which  the  gastric  disor- 

*  [The  most  recent  discussions  of  this  subject  will  be  found  in  Bouchard's  Lec- 
tures on  Autointoxication  in  Disease,  translated  by  Thos.  Oliver,  Philadelphia, 
1894;  and  Albu's  monograph,  Ueber  die  Autointoxicationen  des  Intestinaltractus. 
Berlin,  1895.— Ed.] 

f  Senator.  Berl.  klin.  Wochenschr.,  1868,  No.  24.  Emminghaus,  ibid.,  1873, 
S.  477. 

X  Kulneff.     Beitrage  zur  Kenntniss  der  Autointoxicationen,  II. 


160  DISEASES  OF   THE   STOMACH. 

der  runs  so  rapid  a  course  tliat  there  is  no  time  for  tlie  development 
of  the  general  and  mutual  functional  disturbances  just  described. 
This  occurs  only  in  a  comparatively  few  cases  of  so-called  acute 
gastritis ;  in  all  the  others  there  is  ample  time,  even  though  we 
designate  them  acute. 

To  correctly  understand  these  phenomena  another  factor  must 
be  considered,  namely,  the  antifermentative  action  of  hydrochloric 
acid. 

Even  Spallanzani*  had  observed  that  small  pieces  of  meat 
which  had  been  soaked  in  gastric  juice  did  not  decompose  even  after 
standing  for  a  number  of  days.  Gastric  juice  containing  HCl  may 
be  left  exposed  to  the  air  for  a  week  or  longer  without  the  develop- 
ment of  any  fungi  or  any  putrefaction ;  but  the  growth  of  micro- 
organisms soon  makes  it  turbid  and  foul  if  free  HCl  is  absent.  In- 
vestigations which  I  made  have  shown  that  loosely  combined  HCl 
can  not  retard  this  putrefaction.  The  same  has  been  found  by 
Kabrehl  and  Cohn.f  The  marked  antifermentative  power  of  HCl 
has  long  been  known  (Sieber,  Miquel),  and  recently  some  writers, 
like  Bunge, :{:  have  even  considered  the  antibacterial  or  antifermen- 
tative action  against  the  countless  bacteria  which  are  being  contin- 
ually introduced  into  the  stomach  as  the  chief  function  of  the  gastric 
juice.  Falk,  Wesener,  Loffler,  Miller,  and  recently  Kabrehl  and 
Hamburger,*  have  investigated  the  action  of  the  gastric  juice  upon 
pathogenic  bacteria  and  have  demonstrated  its  destructive  power 
upon  them.  On  the  other  hand,  Minkowski  ||  has  correctly  urged 
that  the  stomach  can  not  be  regarded  as  a  certain  sterilizer,  but  that 
it  is  only  able  to  restrict  the  processes  of  decomposition  within  cer- 
tain limits.  One  might  also  be  inclined  to  agree  with  Minkowski, 
that  in  the  living  organism  along  with  the  action  of  the  HCl  there  is 


*  See  Ewald.    Klinik,  etc.,  I.  Theil,  3te  Auflage,  p.  137  et  seq. 

\  Kabrehl.  Einwirkung  des  kimstlichen  Magensaftes  auf  pathogene  Mikro-or- 
ganismen.  Zeitschr.  fiir  Hygiene,  Bd.  x,  Heft  3. — F.  0.  Cohn.  Zeitschr.  fiir  physi- 
olog.  Chemie,  Bd.  xv,  Heft  1. 

I  Bunge.     Lehrbuch  der  physiolog.  Chemie,  2te  Auflage,  1889,  p.  143. 

*  H.  Hamburger.  Ueber  die  Wirkung  des  Magensaftes  auf  pathogene  Bakterien. 
Jnaug.  Dissert.,  Breslau,  1890. 

II  Minkowski.  Ueber  Gahrungen  im  Magen.  Mittheilungen  aus  der  med.  Klinik 
in  Konigsberg,  1888. 


MUTUAL  RELATIONS  OP  STOMACH.  161 

also  some  influence  for  the  pepsin — i.  e.,  the  specific  peptic  digestion 
of  organic  substances ;  but  Macfadyen,*  and  later  Colin,  have  shown 
that  pepsin  takes  no  part  in  the  antiseptic  action  of  the  gastric  juice. 
Hamburger  details  an  experiment  according  to  which  the  HCl  com- 
bined with  peptones  may  kill  bacteria,  "  provided  it  is  present  in 
sufiicient  quantities." 

But  the  cases  of  purely  intestinal  digestion  which  have  already 
been  mentioned  a  number  of  times,  in  which  the  gastric  juice  is 
permanently  insufficient  and  free  from  HCl,  and  in  which,  neverthe- 
less, digestion  is  satisfactory,  prove  that  the  absence  of  disinfection 
in  the  stomach  does  not  produce  any  bad  efEects.  Furthermore,  in 
acute  gastritis  in  which,  as  it  appears,  free  HCl  is  absent  as  a  rule, 
only  slight  decomposition  occurs  in  the  food.  On  the  other  hand,  it 
must  be  borne  in  mind  that,  according  to  the  experiments  of  Miller,f 
and  a  very  interesting  case  of  McNaught,:]:  even  gastric  juice  con- 
taining HCl  may  be  unable  to  prevent  certain  processes  of  fermen- 
tion.  [Since  then  this  has  been  corroborated  by  many  observers, 
among  whom  Kaufmann,  Strauss,  and  Riegel  may  be  mentioned.] 

McNaught's  case  was  one  of  gastrectasis  from  pyloric  stenosis  in  which 
inflammable  gas  was  formed,  as  occurred  in  similar  cases  which  have  been 
described  by  Ewald,  Schultze,  Beatson,  and  others.  McNaug-ht  not  alone 
repeatedly  found  HCl  in  quantities  as  high  as  12"2  per  mille,  but  the  stom- 
ach contents  were  so  rich  in  yeast  cells,  sarcinae,  and  bacteria,  that  he  was 
able  to  infect  sterilized  milk  and  produce  inflammable  gas.  Cultures 
showed  the  presence  of  a  clostrydiiim  butyricum,  which  was  like  that  of 
Prazmowski,  but  which  was  not  exactly  identical  with  it. 

I  may  add  that  it  is  by  no  means  unusual  to  encounter  patients 
with  dilated  stomachs  who  suffer  from  marked  production  of  gas, 
although  much  free  HCl  may  always  be  found  in  the  stomach  con- 
tents. In  these,  and  in  the  cases  quoted  above,  we  must  remember 
tliat  it  is  well  known  that  certain  micro-organisms  may  thrive  on 
acid  media,  and  that  fermentation  is  dependent  in  some  cases  upon 

*  Macfadyen.  The  Behavior  of  Bacteria  in  the  Digestive  Tract.  Journal  Anat. 
and  Physiol.,  1887.  vol.  xxi. 

f  Miller.  Ueber  Gahrungsvorgange  ira  Verdauungstractus  und  die  dabei  be- 
theiligten  Spaltpilze.  Deutsch.  med.  Wochenschr.,  1885,  No.  xlix,  and  1886,  No. 
viii. 

X  McNaught.  A  Case  of  Dilatation  of  the  Stomach  accompanied  by  the  Eructa- 
tion of  Inflammable  Gas.     Brit.  Medical  Journal,  March  1,  1890. 


162  DISEASES  OF   THE  STOMACH. 

the  relation  of  the  micro-organisms  to  the  quantity  of  HCl  present, 
and  in  other  cases  on  the  more  or  less  rapid  transfer  of  the  contents 
of  the  stomach  into  the  intestines.  Nevertheless,  the  value  of  HCl 
as  an  antifermentative  in  the  antisepsis  of  the  stomach  and  intes- 
tines remains  unquestioned ;  and  we  must  assume,  when  there  are 
no  disturbances  corresponding  to  the  absence  of  HCl,  that  it  has  been 
replaced  by  increased  motor  activity  of  the  stomach.  This  is  shown 
by  the  occurrence  of  numerous  dyspeptic  symptoms  which  are  due 
to  the  remarkably  rapid  decomposition  where  there  is  a  deficiency 
or  absence  of  HCl,  and  an  insufficient  vicarious  increase  of  the  peri- 
stalsis of  the  stomach. 

That  even  when  there  is  a  complete  absence  of  HCl — ^i.  e.,  when 
gastric  digestion  is  absolutely  at  a  standstill — the  food  may  for  a 
time  be  absorbed  and  the  bodily  weight  maintained,  has  been  shown 
long  ago  by  Wolff  and  myseK,  Grundzach  and  others.*  The  conclu- 
sion arrived  at  has  been  that  the  intestinal  digestion  acts  vicariously 
and  replaces  the  deficiency  in  the  peptic  digestion.  This  fact,  which- 
is  self-evident  when  it  is  borne  in  mind  that  the  bodily  weight  does 
not  sink  in  these  cases,  has  been  confirmed  by  Yon  !Noorden's  f 
exact  researches. 

The  relation  'between  the  amount  of  HCl  secreted  am^d  the  acid- 
ity of  the  urine  I  have  already  carefully  considered  elsewhere ;  :j: 
here  I  shall  merely  recapitulate  that  any  diminution  in  the  acidity 
of  the  urine  is  due  to  some  loss  in  the  acidity  of  the  organism,  such 
as  vomiting  or  siphoning  out  acid  stomach  contents,  hyperchlorhy- 
dria,*  or  the  combination  of  an  excessive  amount  of  secreted  HCl 
with  bases,  thus  forming  msoluble  salts  (calcium  or  magnesium  salts). 
Even  the  physiological  secretion  of  HCl  during  digestion  represents 


*  [Langenbach  (Deutsch.  med.  Woeh.,  1894,  No.  52)  has  shown  that  the  stomach 
may  be  practically  entirely  dispensed  with,  for  in  cases  of  extensive  gastric  cancer, 
in  which  almost  the  entire  stomach  was  exsected,  the  patient  survived  in  spite  of 
the  fact  that  the  stomach,  which  was  constructed  by  sewing  the  pyloric  and  cardiac 
ends  together,  was  no  larger  than  a  hen's  egg.  The  patient  was  in  excellent  health 
6^  months  after  the  operation. — Ed.] 

t  Von  Noorden.  Ueber  die  Ausnutzung  der  Nahrung  bei  Magenkranken.  Zeit- 
schr.  fiir  klin.  Med.,  Bd.  xvii. 

X  Ewald.     Klinik,  etc.,  I.  Theil,  3te  Auflage,  p.  88  et  seq. 
■    *  Stroh.     Ueber  die  Anomalien  der  Chlorausscheidung  bei  Magenkranken.     In- 
aug.  Dissert.,  Giessen,  1890. 


INFLAMMATION  OF   STOMACH.  163 

such  a  loss ;  this  is  more  or  less  compensated  by  reabsorption  and 
the  simultaneous  or  subsequent  secretion  of  alkaline  juices,  especially 
the  pancreatic ;  yet  it  is  shown  in  the  varying  degrees  of  acidity  of 
the  urine  at  various  times  during  the  day.  This  will  be  much  more 
marked  in  those  cases  where,  as  in  the  abnormal  conditions  cited 
above,  acid  or  acid-forming  salts  are  withdrawn  from  the  blood. 

[Attempts  have  been  made  by  Herschell  *  and  others  to  estimate 
the  acidity  of  the  stomach  contents  from  that  of  the  urine.  Ma- 
thieu  and  Treheux  f  have  carefully  studied  this  question  on  12  per- 
sons after  84  meals ;  over  400  estimations  of  the  degree  of  acidity 
of  the  stomach  contents  and  urine  were  made.  Their  conclusions 
are  that  there  is  a  relation  between  the  two,  yet  so  many  factors 
influence  these  two  curves  of  acidity  that  we  are  at  present  unable 
to  draw  any  practical  conclusions  from  them. 

Attempts  have  also  been  made  to  use  the  amount  of  indican  in 
the  urine  as  a  guide  to  the  amount  of  hydrochloric  acid  secreted. 
Simon,:]:  in  an  excellent  essay,  has  carefully  investigated  tliis  sub- 
ject, and  beheves  that  by  means  of  the  indican  reaction  much  infor- 
mation may  be  obtained  as  to  the  varying  degrees  of  acidity  of  the 
stomach  contents,  and  that  we  are  also  enabled  to  closely  follow  the 
results  of  treatment  in  cases  of  gastro-intestinal  disease. 

For  the  relation  of  hyperchlorhydria  and  the  urinary  chlorides, 
see  Chapter  YIII.] 

I  shall  now  consider  the  pathological  conditions. 

A.Gute  {and  chronic)  inflmnmations  of  the  gastric  mucous  mem,- 
hrcme  are  generally  described  as  acute  (or  chronic)  catarrh  of  the 
stomach,  and  in  this  way  an  entirely  erroneous  conception  of  the 
existing  process  is  created.  According  to  our  present  view,  every 
catarrh  is  nothing  but  an  inflammatory  process,  which  we  call  "  ca- 
tarrh "  if  it  essentially  involves  an  epithelial  and  subepithelial  coat 
with  relatively  few  glandular  elements ;  in  this  case  the  latter  are 
especially  muciparous  glands.    The  structure  of  the  gastric  mucosa — 


*  [Herschell.     On  Indigestion.     London,  1893,  p.  93.— Ed.] 

f  [Mathieu  et  Treheux.     Arch.  gen.  de  med.,  November,  1895. — Ed.] 

X  [Simon.     The  Modern  Aspects  of  Indicanuria,  with  Special  Reference  to  the 

Relations  between  Indican  and  the  Acidity  of  the  Gastric  Juice,     Amer.  Jour,  .of 

Med.  Sciences,  1895,  vol.  ex,  pp.  48  and  157. — Ed.J 


164:  DISEASES  OP   THE  STOMACH. 

better  designated  the  glandular  layer  of  the  stomach,  or  the  tnnica 
glandularis — is  such  that  it  is  out  of  the  question  to  call  it  a  mucous 
membrane  in  the  ordinary  meaning  of  this  term ;  it  is  rather  an 
aggregation  of  numerous  tubular  glands  placed  alongside  of  one 
another,  with  excretory  ducts  and  epithelial  cells.  The  structure  is 
thus  a  glandular  parenchyma  with  its  attributes,  interstitial  connect- 
ive tissue,  and  excretory  ducts  ;  it  is  simply  a  peculiar  feature  of  the 
inner  layer  of  the  stomach  that  the  protoplasm  of  the  epithelium  of 
these  excretory  ducts  possesses,  to  a  remarkable  degree,  the  property 
of  becoming  converted  into  mucus ;  in  other  words,  it  is  a  mucin- 
ogenous  substance  in  the  same  way  that  the  epithelium  of  the  true 
glandular  tubules  is  filled  with  a  pepsinogenous  material. 

Therefore,  such  being  the  structure  of  the  gastric  mucous  mem- 
brane, every  inflammatory  process  which  involves  it  necessarily 
also  attacks  the  gastric  glands,  unless  it  is  limited  to  the  excretory 
ducts.  The  latter  is  opposed  to  the  results  of  chnical  observation. 
Beaumont's  investigation  on  his  patient,  Alexis  St.  Martin,  showed 
that  every  "  catarrh,"  even  the  mildest,  was  accompanied  by  a  dis- 
turbance of  the  secretion  of  gastric  juice,  consequently  by  an  affec- 
tion of  the  glands  themselves.  Thus  the  inflammation  is  not  ca- 
tarrhal, but  parenchymatous  and  interstitial ;  it  has  nothing  in  com- 
mon with  a  catarrh  except  the  "  flow  "  (the  secretion  of  a  more  or 
less  abundant  but  always  alkaline  transudate  into  the  cavity  of  the 
stomach),  but  which  it  far  exceeds,  owing  to  the  accompanying  dis- 
turbance of  the  specific  secretion.  In  this  respect  I  fully  agree  with 
the  views  expressed  by  F.  A.  Hoffmann,*  and  especially  that,  being 
misled  by  the  term  "  catarrh,"  we  are  generally  too  prone  to  under- 
estimate the  importance  of  these  processes,  particularly  when  they 
are  chronic,  and  that  by  thinking,  for  example,  of  a  chronic  pharyn- 
geal catarrh  we  lose  all  proper  standards  of  comparison.  Conse- 
quently, if  in  the  following  pages,  from  the  force  of  habit,  I  should 
speak  of  an  acute  or  chronic  gastric  catarrh,  I  shall  nevertheless 
always  have  in  mind  a  gastritis,  or,  better,  a  gastroadenitis,  which 
pursues  an  acute,  subacute,  or  chronic  course. 

According  to  the  etiology,  we  can  distinguish  the  following  va- 

*  F.  A.  HofEmann.    Vorlesungen  iiber  allgeraeine  Therapie.     Leipzig,  I880,  pp. 
169  et  seq. 


SIMPLE   ACUTE   GASTRITIS.  165 

rieties  of  acute  gastritis  :  gastritis  glandularis  acuta  simplex  (acute 
gastric  catarrh),  sympathica,  toxica,  phlegmonosa,  idiopathica,  and 
metastatica. 

Simple  Acute  Gastritis ;  Occurrence  and  Etiology. — Tliis  lesion  is 
so  common,  and  its  causes  are  of  sucli  everyday  occurrence,  tliat 
it  forms  one  of  the  most  familiar  diseases  with  which  we  are  ac- 
quainted. Every  acute  gastritis  is  really  a  toxic  gastritis  in  the 
sense  of  a  local  irritation  such  as  is  produced  by  toxic  (i.  e.,  locally 
irritating  and  corroding)  substances.  In  this  same  way  every  over- 
loading of  the  stomach  may  be  said  to  act  "  toxically,"  smce  every 
excess  is  followed  by  a  number  of  symptoms  of  irritation  which 
finally  cause  an  acute  inflammation.  :N"aturally,  our  conception  of 
too  much  is  only  relative,  and  quantities  of  food  which  under 
normal  conditions  are  disposed  of  without  any  delay,  may  under 
abnormal  circumstances  have  an  injurious  effect.  A  convalescent 
gets  an  acute  gastric  catarrh  after  eating  a  beefsteak  which  he 
could  easily  digest  when  he  is  healthy.  A  man  who  has  almost 
starved  to  death  must  return  to  his  usual  diet  very  cautiously  and 
gradually.  Three  of  the  fifteen  shipwrecked  sailors  of  the  Medusa 
died  because  they  ate  too  ravenously  after  their  rescue. 

Many  persons  have  a  kind  of  predisposition  to  gastric  catarrh, 
just  as  others  are  afflicted  with  a  predilection  toward  catarrhs  of  the 
nose  and  throat ;  such  people  are  made  ill  both  by  the  quantity  and 
quality  of  certain  articles  of  food  which  have  no  effect  on  a  healthy 
stomach.  In  some  this  predisposition  is  decidedly  hereditary.  Al- 
though none  of  the  text-books,  with  the  exception  of  Lebert,  men- 
tions this  circumstance,  yet  I  have  no  reason  to  doubt  it,  since  too 
many  patients  have  assured  me,  either  spontaneously  or  after  ques- 
tioning, that  the  father  or  mother  had  suffered  from  a  weak  stom- 
ach, or  that  their  brothers  or  sisters  were  equally  predisposed. 
Hoffmann  *  says,  "  Every  one  has  the  stomach  which  he  deserves  "  ; 
nevertheless,  great  injustice  might  be  done  thereby  to  a  large  num- 
ber of  persons  who,  without  being  dyspeptics,  suffer  from  weak 
stomachs.  For  it  is  well  known  that  there  are  some  patients  (even 
though  their  number  is  small)  who  take  the  greatest  possible  care  of 

*  F.  A.  HofEraann,  loc.  cit. 


IQQ  DISEASES  OF  THE  STOMACH. 

their  stomaclis  year  after  year,  but  are  nevertheless  unable  to  pre- 
vent an  attack  of  acute  or  chronic  catarrh  which  could  in  no  way 
have  been  surmised  beforehand. 

Irritation  may  be  caused  both  by  the  quality  of  the  food  as  well 
as  its  quantity.     Spoiled  articles  of  food  and  drink  may  even  cause 
inflammation  of  the  mucous  membrane  of  the  stomach,  probably  on 
account  of  the  inflammatory  and  fermentative  action  of  the  microbes 
which  have  been  introduced  with  them  ;  thus  we  might  speak  of  a 
bacillary  infection,  if  by  this  we  understand  quite  generally  that  the 
disturbances  are  to  be  referred  to  the  action  of  the  micro-organisms, 
and  not,  of  course,  to  a  direct  invasion  of  them.     Furthermore,  it 
has  frequently  struck  me  that,  in  the  various  cases  in  which  I  have 
had  the  opportunity  of  examining  pieces  of  human  mucous  mem- 
brane while  still  warm  from  the  body,  I  have  never  found  so  much 
as  a  trace  of  bacteria  in  the  tissues,  although  they  are  so  abundant  in 
the  contents  of  the  stomach.    Yet  1  must  confess  that  I  have  studied 
this  point  superficially  rather  than  with  great  attention  to  details. 
Meanwhile,  although  in  the  examination  of  six  cases  of  gastritis 
membranacea  diphtheritica  Smirnow  *  found  large  numbers  of  mi- 
crococci and  bacilli  in  the  membranes  lying  upon  the  gastric  mucosa, 
yet  he  could  not  detect  them  in  the  lumen  of  the  glands  or  in  the 
tissues.     But  as  the  abnormal  products  of  decomposition  which  irri- 
tate the  mucous  membrane  of  the  stomach  are  always  due  to  organ- 
ized ferments,  it  is  my  belief  that  acute  gastritis  can  in  this  sense  be 
positively  referred  to  the  action  of  micro-organisms.     It  depends 
only  upon  the  number  introduced  into  the  stomach,  and  upon  the 
question  whether  the  antifermentative  gastric  juice  at  the  individu- 
al's disposal  is  able  to  limit  or  stop  the  decomposition.     Therefore, 
since  we  always  introduce  a  certain  number  of  microbes  with  our 
food,  a  disproportion  must  exist  between  the  two  factors  above  men- 
tioned, the  foreign  intruders  and  the  normal  production  of  acid.    To 
this  disproportion  I  should  also  like  to  refer  the  influence  which 
psychical  factors  and  nervous  disturbances  exert  upon  the  develop- 
ment of  acute  gastric  catarrh.     Under  such  circumstances  weak  gas- 
tric juice  is  secreted,  the  motor  and  expulsive  powers  of  the  stomach 


*  G.  Smirnow.     Ueber  Gastritis  metabranacea  und  diphtheritica.     Virchow's 
Archiv,  Bd.  cxiii,  S,  333. 


SIMPLE   ACUTE   GASTRITIS.  16T 

are  enfeebled ;  hence  any  causes  of  fermentation  which  may  have 
been  introduced  are  allowed  to  grow  more  rapidly  and  abundantly. 
But  surely  there  is  at  no  time  a  lack  of  causes  of  fermentation ;  we 
are  constantly  introducing  them  in  our  food  and  drink. 

Among  the  products  of  fermentation  the  first  to  attract  our  at- 
tention is  lactic  acid.  The  fact  that  it  is  normally  present  in  the 
dio-estion  of  bread  speaks  against  its  having  any  peculiar  irritating 
qualities.  Should  it  persist,  as  we  shall  see  that  it  may  under  cer- 
tain circumstances,  and  be  present  in  large  quantities  in  the  later 
periods  of  digestion,  it  is  then  to  be  regarded  not  as  a  causal  factor 
but  rather  as  a  result.  Furthermore,  it  is  well  known  that  we  can 
give  lactic  acid  medicinally  [as  in  diarrhoea,  diabetes,  etc.]  and  in 
beverages  (kefir  and  kumyss),  not  only  without  harm  but  with  bene- 
fit to  the  stomach.  Furthermore,  I  have  had  the  opportunity  of  ex- 
amining the  stomach  contents  in  several  cases  of  acute  gastritis  im- 
mediately after  the  beginning  of  the  attack.  One  case  concerns  me 
personally.  I  was  suddenly  taken  sick  during  the  night  without 
having  committed  any  dietetic  error  and  while  leading  a  very  quiet 
life.  I  had  to  vomit  very  frequently ;  at  first  I  raised  large  quan- 
tities of  offensive  stomach  contents,  but  later  only  biliary  mucous 
masses.  The  filtrate  of  the  former  contained  no  free  IICl  and  only 
traces  of  lactic  acid,  while  (to  judge  from  the  reaction)  large  quan- 
tities of  fatty  acids  were  present.  I  examined  the  substances  which 
were  first  vomited  in  three  other  cases  by  inmates  of  a  sanitarium, 
where  acute  gastric  catarrh  is  of  frequent  occurrence  after  holidays 
or  visiting  days.  The  patients  were  between  the  ages  of  fifty  and 
seventy  years,  and  their  digestion  was  otherwise  good.  At  no  time 
did  the  filtrate  of  the  vomited  food  contain  any  free  HCl,  although 
the  reaction  was  faintly  acid  (owing  to  acid  salts) ;  no  lactic  acid 
was  present  in  the  ethereal  extract.  A  slow  digestive  action  was 
obtained  after  adding  enough  HCl  to  give  a  feeble  acid  reaction. 
Fatty  acids  could  be  detected  only  in  very  small  quantities  in  spite 
of  the  intense  rancid  odor.  I  wish  to  lay  particular  stress  upon  the 
fact  that  these  examinr.tions  were  made  immediately  at  the  begin- 
ning of  the  gastritis.  Later  on  we  will  find  only  mucus  and  a  few 
fragments  of  food,  or,  if  the  test  breakfast  has  been  given,  the 

pieces  of  the  roll  will  be  found  undigested,  a  larger  or  smaller 
12 


168  DISEASES   OP   THE  STOMACH, 

amount  of  lactic  acid,  but  no  HCl.  Therefore,  according  to  tliese 
observations,  there  must  be  other  substances  than  lactic  acid  which 
can  produce  the  irritation  necessary  to  cause  gastritis.  It  is  at 
present  a  matter  of  conjecture  whether  it  be  the  fatty  acids  or 
some  products  of  decomposition  as  yet  unknown  to  us.  However, 
I  can  not  believe,  as  for  example  Leube  does,  that  the  mechanical 
irritation  produced  by  undue  retention  of  ingesta  will  alone  suffice 
to  give  rise  to  gastritis.  It  is  true  that  we  commonly  speak  of 
"overloading"  the  stomach;  but  ought  an -organ  which  is  nor- 
mally adapted  to  tolerate  burdens  of  the  most  varied  kind,  and  for 
unequal  periods  of  time,  be  really  irritated  by  the  prolonged  pres- 
sure of  food  ? 

Among  the  chemical  irritants  I  also  include  those  which  are 
toxic  in  the  true  sense  of  this  word — i.  e.,  concentrated  or  diluted 
acids  or  alkalies,  and  metals  like  copper,  antimony,  iodine,  arsenic, 
phosphorus,  etc.  Finally,  I  must  also  mention  thermal  irritation ; 
ingesta  which  are  too  cold  seem  to  do  more  harm  than  those  which 
are  too  hot.  Although  a  draught  of  cold  water  or  beer  is  often 
charged  with  being  the  cause  of  a  gastric  catarrh,  we  scarcely  ever 
hear  of  any  blame  being  attached  to  ice  cream,  which  is  at  least 
equally  cold,  possibly  because  it  is  not  taken  in  such  quantities  or  is 
not  so  hastily  swallowed. 

Pathology. — All  clinicians  and  pathologists  complain  that  our 
knowledge  of  the  changes  in  the  mucous  membrane  in  acute  gas- 
tric catarrh  is  limited,  because  not  alone  is  it  rare  to  encounter  a 
stomach  with  acute  gastritis  at  the  autopsy  table,  but  also  because 
this  viscus  is  always  removed  from  the  body  many  hours  after 
death,  and  hence  the  post-mortem  changes  which  manifest  them- 
selves so  early  and  so  destructively  can  not  be  excluded.  In  my 
opinion,  these  complaints  are  not  entirely  justified,  for  in  very 
many  cases  of  acute  diseases  on  which  autopsies  are  made  there 
exists  an  acute  inflammation  of  the  gastric  mucosa  as  an  accompani- 
ment of  the  ante-mortem  disturbances — high  fever,  anaemia — even 
if  few  or  no  evidences  of  it  can  be  detected  macroscopically.  But 
the  post-moi'tem  changes  can  be  reduced  to  a  minimum  by  washing 
out  the  stomach  immediately  after  death  and  then  filling  it  with 
alcohol.     [Much  light  has  been  shed  on  the  minute  anatomy  of  the 


SIMPLE  ACUTE  GASTRITIS.  100 

gastric  mucosa  by  the  study  of  exfoliated  pieces  of  mucous  mem- 
brane wbicli  are  so  frequently  found  in  washing  out  the  stomach. 
An  elaborate  paper,  with  bibliography  on  this  subject,  has  recently 
been  published  by  Colmheim  ;  *  he  has  been  able  to  demonstrate 
very  extensive  pathological  changes  in  the  various  diseases  of  the 
stomach.  Hayem  f  has  also  devoted  much  attention  to  the  minute 
anatomy  of  acute  gastritis,  and  has  laid  particular  stress  upon  what 
he  calls  acute  parenchymatous  gastritis.  The  correctness  of  his 
views  have  been  denied  by  subsequent  writers,  on  the  ground  that 
what  he  has  observed  is  the  result  of  post-mortem  changes.] 

Consequently  we  must  refer  to  the  experiments  made  on  ani- 
mals, especially  those  of  Ebstein,;};  Losch,*  and  others.  In  studying 
tlie  process  in  human  beings,  I  must  refer  especially  to  the  researches 
of  Edinger,!  Yirchow,  Klebs,  Menassein,  and  others.^  Later  on, 
Sachs,^  Marfan,;!;  G.  Meyer,^  and  myself  J  have  published  a  num- 
ber of  remarkable  and  interesting  facts  upon  this  subject,  the  main 
features  of  which  have  been  confirmed  by  the  subsequent  observa- 
tions of  W.  Fenwick,  Schwalbe,  Stintzig,  Westphalen,  and  Fischl.** 

*  [Cohnheim.  Die  Bedeutung  kleiner  Schleimhautstuckchen  fur  die  Diagnostik 
der  Magenkrankheiten.  Boas's  Arch,  fiir  Verdauungskrankheiten,  1895,  Bd.  i,  p. 
274.— Ed.] 

f  [Hayera.     Semaine  med.,  October  27,  1894. — Et).] 

X  Ebstein.  Ueber  die  Veranderungen  welche  die  Magenschleimhaut  durch  Ein- 
verleibung  von  Alkohol  und  Phosphor  erleidet.     Virehow's  Arehiv,  Bd.  Iv,  S.  469. 

*  Losch.  Ueber  die  nach  Einwirkung  abnormer  Reize  auf  die  Magenschleim- 
haut auftretende  pathologisch-anatomischen  Veranderungen.  Allgeineine  Wiener 
med.  Zeitung,  1881,  No.  50. 

II  Edinger.  Zur  Kenntniss  der  Drlisenzellen  des  Magens,  besonders  beira  Men- 
schen.     M.  Schultze's  Arehiv,  Bd.  xvii,  S.  209. 

^  R.  Virchow.  Der  Zustand  des  Magens  bei  Phosphorvergiftung.  Virehow's 
Arehiv,  Bd.  xxxi,  S.  399.— Klebs.  Handbuch  d.  patholog.  Anatomic,  1868,  S.  174. 
— Menassein,  Chera.  Beitrage  zur  Fieberlehre.  Virch.  Arch.,  Bd.  Iv,  S.  452. — 
Uffelmann.  Beobachtungen  an  einem  Gastrotomirten,  Deutsch.  Arch,  fur  klin. 
Med.,  Bd.  xxvi,  S.  441. 

0  A.  Sachs.  Zur  Kenntniss  der  Magenschleimhaut  in  krankhaften  Zustanden. 
Arch,  filr  experiment.  Pathologic,  Bd.  xxii.  Heft  3,  and  Bd.  xxiv,  Hefte  1,  2. 

^  Marfan.  Troubles  et  lesions  gastriques  dans  la  phthisic  pulmonaire.  Paris, 
1887. — Stintzig,  Miinchener  med.  Wochenschr.,  1890. 

$  G.  Meyer.     Zeitschr.  fiir  klin.  Med.,  Bd.  xvi,  Hefte  3  und  4. 

J  Ewald.  Diseases  of  the  Stomach.  Translated  by  Manges,  1892,  pp.  318 
et  seq. 

**  W.  Fenwick.  Zusammenhang  zwischen  Magen  und  Organerkrankungon.  Vir- 
ehow's Arch.,  Bd.  cxviii,  p.  2. — Schwalbe.  Die  Gastritis  der  Phthisiker  voni  (latho- 
logisch-anatomischcn  Standpunkte.     Virehow's  Arch.,  Bd.  cxvii,  p.  310. — Stintzi.:. 


170  DISEASES  OP  THE  STOMACH. 

According  to  my  experience,  a  human  stomach  with  an  entirely 
normal  mucous  membrane  is  among  the  greatest  rarities,  at  least 
after  the  fortieth  year,  and  is  found  only  in  persons  who  have  met 
with  a  sudden  death.  I  possess  the  stomachs  of  two  persons,  both  of 
whom  were  instantly  killed,  one  by  the  entrance  of  a  piece  of  meat 
into  the  larynx,  and  the  other  by  injuries  received  from  machinery. 
I  was  able  to  remove  the  first  stomach  immediately  after  death,  and 
the  second  a  short  time  after,  and  placed  both  in  absolute  alcohol. 
Both  specimens  present  an  exquisite  picture  of  the  normal  gastric 
mucous  membrane  with  distinct  differentiation  between  the  ^Darietal 
and  principal  cells.  On  comparing  sections  from  other  stomachs 
with  these  I  find  that  they  all  show  more  or  less  marked  changes, 
the  most  conspicuous  of  which  is  an  infiltration  of  the  interstitial 
connective  tissue  with  numerous  round  cells,  which  have  also  wan- 
dered to  the  free  surface  of  the  mucosa.  Should  the  gastric  func- 
tions have  suffered  during  the  last  days  of  life,  or  if  the  symptoms 
of  an  inflammatory  condition  have  appeared,  as  is  generally  the  case, 
then  in  most  portions  of  the  fundus  no  difference  between  the  pa- 
rietal and  principal  cells  can  be  detected,  and  instead  we  find  that 
all  the  cells  have  alike  become  granular  and  cloudy,  that  in  part  they 
have  become  separated  from  the  membrana  propria  of  the  glands,  and 
have  diminished  in  size.  Here  and  there  we  may  find  cysts  which 
contain  either  the  remains  of  epithelial  cells  or  simply  only  a  lining 
membrane.  The  mucous  cells  are  especially  abundant  in  the  pyloric 
region,  and  extend  down  deeply  into  the  ducts  of  the  glands. 

On  the  whole,  this  description  agrees  with  that  given  by  the 
authors  mentioned  above,  and  the  condition  which  I  have  pictured 
indicates,  first,  that  an  active  inflammatory  irritation  must  exist 
which  expresses  itself  in  an  abundant  cellular  proliferation ;  sec- 
ondly, that  there  is  a  condition  of  continuous  activity  of  the  glandu- 
lar cells  which  does  not  permit  the  secretion  to  collect  in  them,  and 
hence  does  give  the  customary  appearance  of  the  cells  of  the  glands 
in  the  condition  of  rest.  At  least  this  is  the  view  of  the  authors 
mentioned,  so  far  as  they  embrace  Heidenhain's  views. 

Miinehen.  med.  Wochenschr.,  1889,  No.  8.— Westphalen.  St.  Petei'sburg.  Woehen- 
schr.,  1890,  Nos.  37  and  38,  and  1891,  No.  21.— Fischl.  Prager  .Zeitsehr.  fur  Heil- 
kunde,  1891,  Heft  3. 


SIMPLE  ACUTE   GASTRITIS.  171 

I  think  I  ouglit  to  say  here  that  this  condition  of  the  cells,  which 
is  ascribed  to  continuous  activity,  may  be  produced  equally  well  by 
a  complete  cessation  of  their  function  ;  for  either  the  secretion  is 
formed  in  the  cell,  and  is  so  rapidly  removed  that  none  can  collect 
there,  or  thei'e  is  absolutely  none  produced.  In  either  case  the  re- 
sulting picture  in  the  cell  will  be  the  same. 

I  will  gladly  concede  an  increased  cellular  activity  in  the  early 
stages  of  acute  gastritis  as  a  result  of  inflammatory  irritation,  but 
this  does  not  necessarily  mean  thai  the  product  is  improved  in  qual- 
ity ;  on  the  contrary,  the  stomach  may  pour  forth  a  secretion  which 
is  continuous,  but  is  very  deficient  m  active  constituents.  I  wish 
to  say  now,  to  anticipate  a  little,  that  in  the  later  stages  in  acute  and 
chronic  inflammation  this  does  not  apply.  For  not  alone,  according 
to  a  universal  pathological  law,  do  chronic  inflammations  paralyze 
the  specific  function  of  the  involved  viscus,  but  we  also  know  di- 
rectly that  in  chronic  catarrhs,  especially  those  which  are  accom- 
panied by  a  profuse  secretion  of  mucus,  the  secretion  is  markedly 
impoverished  in  its  specific  ingredients,  and  consists  of  pure  mucus. 
Sachs,  in  the  work  already  quoted,  lays  great  stress  on  the  karyoki- 
netic  figures  which  may  be  seen  partly  in  the  leucocytes  in  the  inter- 
glandular  tissue,  partly  in  the  superficial  epithelial  cells,  and  partly 
in  the  cells  of  the  "mucous  glands  of  the  stomach,"  and  which  afford 
additional  proof  of  the  active  cell  proliferation  which  occurs  in  these 
processes.  I  have  tepeatedly  seen  indications  of  this  karyokinesis, 
but  never  such  distinct  pictures  as  are  drawn  by  Sachs.  So  far  as 
our  present  knowledge  goes,  they  do  not  seem  to  have  any  special 
pathognomonic  significance. 

Macroscopically  the  mucous  membrane  appears  entirely  or  par- 
tially swollen  and  reddened,  and  marked  here  and  there  with  small 
suggillations.  Even  to  this  day  Beaumont's  Canadian  [St.  Martin] 
remains  the  classical  witness  for  the  appearance  of  the  gastric  wall 
in  such  a  condition ;  "  its  surface  was  marked  with  numerous 
white  spots  and  vesicles  like  coagulated  lymph,  between  which  were 
very  dark-red  spots,"  while  food  could  be  found  in  the  hollow  of 
the  pylorus  unchanged  and  surrounded  by  a  capsule  of  yellow  mu- 
cus, as  long  as  four  hours  after  ingestion. 

Symptoms. — Authors,  especially  the   French,  have  taken   great 


172  DISEASES  OP  THE  STOMACH. 

pains  to  establish  various  forms  of  acute  inflammation  of  the  stom- 
ach. Thus  Lebert  distinguislies  between  an  acute  gastric  irritation 
due  to  overloading,  indigestion,  and  an  acute  painless  catarrh  with 
disturbance  of  a  nature  more  functional ;  the  latter  he  subdivides 
into  the  afebrile  and  the  infectious  febrile  varieties ;  and  finally  he 
describes  an  acute  inflammatory  catarrh.  On  closer  inspection  it 
will  be  seen  that  these  are  only  artificial  subdivisions,  and  that  it  is 
more  in  accordance  with  ISTature  to  recognize  onlj  two  great  groups, 
t/ie  afebrile  and  the  febrile  catarrh.  The  latter  is  simply  an  exag- 
geration of  the  former,  but  it  may  occasionally  follow  so  rapid  a 
course  that  an  acute  febrile  gastritis  with  high  fever  may  be  at 
once  developed. 

Immediately  after  a  manifest  indiscretion  of  diet,  etc.,  nausea 
suddenly  appears,  together  with  a  feeling  of  fullness,  tension  and 
swelling  of  the  epigastrium,  tenderness  on  pressure  over  this  region, 
thirst,  anorexia,  and  even  disgust  for  food ;  accompanying  these,  or 
at  the  onset,  are  the  general  symptoms  of  giddiness,  headache,  flashes 
before  the  eyes,  and  prostration.  In  addition,  we  find  the  tongue 
coated ;  at  the  beginning  especially  the  organ  is  often  completely 
covered  with  a  thick,  tenacious  white  fur,  which  may  be  colored  by 
food  or  drugs,  and  which  retains  the  impressions  of  the  teeth ;  as 
the  disease  advances  it  tends  to  clear  up  at  the  tip  and  edges.  At 
times  herpes  labialis  develops.  There  is  diffuse  pain  on  pressure 
over  the  region  of  the  stomach,  and  painful  spasms  may  also  appear. 
The  pulse  is  small  and  rapid,  the  secretion  of  saliva  is.  increased,  the 
oesophagus  contracts  painfully;  spasmodic  yawning  is  also  some- 
times observed.  The  face  becomes  pale,  the  eyes  are  expressionless, 
the  extremities  cold,  and  a  quite  specific  odor  is  exhaled  from  the 
skin.  J^ow  nausea  and  vomiting  set  in  ;  the  latter,  even  if  it  occurs 
some  time  after  a  meal,  consists  of  the  ingesta  only  slightly  changed, 
and  inclosed  in  thick  masses  of  mucus ;  the  vomit  has  a  flat  or  very 
penetrating  odor,  and  an  exceedingly  bitter  taste.  However,  this  is 
not  due  to  bile,  as  the  common  expression  "as  bitter  as  gall"  would 
lead  us  to  suppose,  but  to  the  acrid  taste  of  the  peptones,  together 
with  the  fatty  acids,  such  as  we  find  in  every  artificial  digestion — 
e.  g.,  peptonizing  milk.  Fresh  bile  is  not  bitter  ;  it  is  tasteless.  I 
have  repeatedly  proved  this  in  cases  in  which  the  introduction  of 


SIMPLE   ACUTE   GASTRITIS.  173 

the  stomach  tube,  and  the  efforts  at  bearing  down  having  caused  a 
regurgitation  from  the  duodenum,  pure  bile  (chemically  tested)  has 
been  brought  up.  Lauder  Brunton  *  has  made  the  same  observa- 
tions. The  vomiting  tends  to  be  repeated  many  times,  and  finally 
only  mucus  and  bile  are  raised.  At  first  it  occurs  easily,  but  later 
becomes  very  painful,  depending  upon  whether  the  spasms  involve 
the  fundus  or  the  orifices,  thus  rendering  the  act  of  emesis  more  dif- 
ficult— a  point  to  which  Skoda  has  directed  attention.  The  reaction 
of  the  vomited  matter  is  neutral  or  faintly  acid ;  we  never  find  free 
hydrochloric  acid,  but  fatty  and  lactic  acids ;  at  the  same  time  the 
latter  are  not  constant,  their  presence  depending,  as  I  have  said 
above,  upon  whether  the  last  meal  contained  a  large  amount  of  sub- 
stances which  can  produce  lactic  acid.  Although  the  bowels  are 
constipated  at  first,  the  passage  of  the  chyme  into  the  intestines  irri- 
tates the  mucous  membrane  of  the  latter,  causing  borborygmi,  which 
may  sometimes  be  heard  even  at  a  distance,  the  expulsion  of  offen- 
sive fiatus,  and  watery  stools,  accompanied  by  some  tenesmus. 

Under  proper  care  the  condition  disa23pears  in  three  to  five  days, 
or  it  becomes  subacute  or  chronic. 

Febrile  catarrh  is  distinguished  from  the  afebrile  form  only  by 
the  greater  intensity  of  the  symptoms  and  the  occurrence  of  fever 
from  the  onset.  The  latter  appears  suddenly  and  may  reach  40°  C. 
[104°  Fahr.]  or  more.  The  skin  becomes  dry  and  livid  and  the 
rapidity  of  the  pulse  is  increased.  There  is  no  proof,  such  as  is  ac- 
cepted to-day — i.  e.,  bacillary  infection — for  the  infectious  febrile 
gastric  catarrh  of  Lebert.  Formerly  these  cases  were  called  gastric 
fever,  and  were  classified  with  typhoid  fever,  but  we  have  since 
learned  to  sharply  differentiate  these  two  conditions,  owing  to  our 
better  knowledge  of  the  nature  of  the  latter.  F.  Schmidt  f  at- 
tempted to  "rescue"  gastric  fevers's  existence  as  "an  infectious  dis- 
ease peculiar  to  itself  "  as  the  result  of  observing  a  small  epidemic 
among  soldiers  that  could  not  be  attributed  to  a  typhoid  infection ; 
unfortunately,  the  most  important  factor,  the  proof  of  infection,  is 
lacking.    The  same  is  true  of  an  epidemic  among  the  inmates  of  the 

*  Loc.  cit.,  p.  54. 

f  F.  Schmidt.  Zur  Prage  nach  der  Existenz  des  gastrischen  Fiebers  als  einer 
cigenartigen  Krankheit.     Dissertation,  Berlin,  1885. 


174  DISEASES  OF  THE  STOMACH. 

Stuttgart  Orphan  Asylum  described  by  Gussmann,*  in  wliicli  24 
out  of  108  children  (22-3  per  cent)  were  taken  sick  with  an  acute 
febrile  gastric  catarrh,  running  a  rapid  course,  with  temperatures  as 
high  as  104-6°  C.  [105°  Fahr.].  The  disease  ran  its  course  with  the 
usual  symptoms,  with  one  striking  exception,  namely,  the  color  of 
the  skin  was  at  first  yellowish,  then  more  of  a  greenish  hue,  and 
finally  dark  red.  Here  it  is  very  natural  to  think  of  an  infection, 
especially  as  the  well-known  toxic  causes  could  be  excluded,  and  as 
attacks  of  acute  gastritis  were  very  prevalent  at  the  same  time  in 
the  city  and  among  the  garrison. 

The  diagnosis  of  simjyle  afebrile  gastritis  is  easily  made.  There 
can  only  be  a  doubt  as  to  whether  the  stomach  was  primarily 
affected,  or  whether  there  was  at  first  a  catarrh  of  the  duodenum 
which  suddenly  "  exploded  upward,"  as  it  were,  in  the  form  of  the 
symptoms  of  acute  gastric  catarrh.  But  in  such  cases  the  tongue  is 
clean,  as  a  rule,  and  the  onset  of  the  specific  gastric  symptoms  is 
usually  preceded  for  a  longer  or  shorter  time  by  the  signs  of  irregu- 
lar intestinal  digestion.  The  stools  have  been  either  irregular,  or 
lessened  in  quantity,  or  the  color  has  indicated  a  deficiency  in  the 
biliary  secretion.  The  result  of  this  sluggishness  of  the  intestines  is 
manifested  in  a  reactive  stagnation  of  the  ingesta ;  the  duodenum 
becomes  filled  and  keeps  back  the  contents  of  the  stomach ;  ^and 
thus  without  any  preceding  dietetic  error  the  symptoms  of  a  gastric 
catarrh  suddenly  appear.  In  my  own  case  which  I  have  mentioned 
above  this  was  obviously  the  course  of  events,  for  it  is  a  fact  that 
the  sudden  vomiting  was  preceded  by  a  period  of  lessened  intestinal 
activity.  !N^ausea  and  anorexia  continued  for  more  than  twenty-four 
hours,  and  were  only  relieved  after  I  had  provided  for  thorough 
evacuation  of  the  bowels  by  means  of  several  fairly  large  doses  of 
calomel.  Such  cases  are  therefore  typical  examples  of  the  reflex 
action  of  the  intestines  upon  the  stomach  which  was  mentioned  at 
the  beginning  of  this  chapter. 

I  have  already  often  called  attention  to  the  condition  of  the 
tongue,  and  shall  do  so  frequently  in  the  following  pages.  Is  the 
appearance  of  the  tongue  really  a  mirror  of  the  stomach,  or  has  it, 

*  Gussmann.    Eine  Epidemie  von  acuter  Gastritis.    Wiirttemb.  Correspondenz- 
blatt,  1888,  No.  23. 


SIMPLE   ACUTE  GASTRITIS.  175 

as  was  held  for  a  long  time,  nothing  whatever  to  do  with  it ;  and 
is  its  condition  to  be  regarded  simply  as  an  index  of  the  existing 
state  of  the  oral  mucous  membrane  ?  In  Henoch's  Kliiiih  der  TJn- 
terleihshrankheiten,^  a  splendid  work  for  its  time,  will  be  found  a 
confirmation  of  the  latter  view  that  the  fur  on  the  tongue  in  dis- 
ease f  denotes  nothing  more  than  a  catarrh  of  the  mucous  mem- 
brane of  the  mouth,  caused  either  by  direct  local  irritation  (such  as 
smoking,  bad  teeth,  periostitis,  angina,  or  drugs),  or  produced  by 
spreading  from  other  mucous  membrane — e.  g.,  the  stomach  and 
intestines.  This  is  undoubtedly  true,  and  we  must  always  bear  in 
mind  the  various  factors  which  may  produce  a  coated  tongue,  in 
order,  in  a  given  case,  to  distinguish  between  local  and  remote 
causes  ;  but  the  uniform  relation  of  the  state  of  the  tongue  and  that 
of  the  stomach  in  all  cases  in  which  a  primary  disease  of  the  mouth 
is  out  of  the  question,  indicates  that  the  existing  relations  must  be 
much  deeper  than  would  be  inferred  from  an  independent  catarrh 
which  received  its  first  impulse  from  the  stomach,  and  persisted 
even  after  the  removal  of  the  gastric  trouble.  Surely  an  uninter- 
rupted reflex  action,  the  direct  nervous  track  of  which  we  can  easily 
trace,  must  exist  here ;  and  the  old  physicians  were  undoubtedly 
right  in  laying  great  stress  on  the  appearance  of  the  tongue  as  an 
indication  of  the  condition  of  the  stomach,  and  in  frequently  making 
it  serve  as  a  guide  for  their  treatment. 

Furthermore,  although  the  condition  of  the  tongue,  even  when 
not  coated  in  the  ordinary  sense  of  the  term,  may  be  very  variable, 
yet  it  may  give  some  information  as  to  the  character  or  cause  of 
the  dyspeptic  manifestations.  Thus,  in  ulcer  of  the  stomach,  it  is 
almost  the  rule  to  find  the  tongue  red,  moist,  smooth,  and  with  a 
thin  white  fur  at  its  base.  In  nervous  dyspepsias  and  neurasthenic 
conditions  the  tongue  is  strikingly  pale,  smooth,  moist,  and  of  a 
bluish  rather  than  a  reddish  tinge  ;  at  times  there  are  also  deep 
transverse  fissures  or  depressions  at  the  side  which  look  like  excori- 
ations, but  are  smoothly  covered  over  by  the  mucous  membrane  ; 

*  Berlin,  1863,  S.  383. 

f  This  does  not  include  the  coating  frequently  found  in  many  persons,  especially 
in  the  morning  and  in  those  who  smoke  excessively,  at  the  base  of  the  tongue, 
which  consists  of  desquamated  epithelium,  detritus,  remnants  of  food,  and  bac- 
teria. 


176  DISEASES  OF  THE  STOMACH. 

the  latter  are  very  annoying.  At  times  tlie  organ  may  seem  to  be 
covered  with,  a  white  fnr,  whereas  this  appearance  is  really  only  due 
to  an  anaemic  condition  of  the  filiform  papillae.  In  other  patients 
the  tongue  feels  swollen  or  enlarged,  causing  them  to  make  incessant 
attempts  at  swallowing,  as  if  they  wished  to  get  rid  of  some  foreign 
body  in  the  mouth  ;  such  a  feeling  is  also  exceedingly  annoying. 

The  recognition  of  acute  febrile  gastritis  may  at  times  not  be  so 
easy.  It  is  true  that  with  a  little  attention  we  can  not  mistake  it  for 
a  beginning  typhoid,  the  steplike  temperature  curve  of  which  is 
quite  characteristic.  But  meningitis,  peritonitis,  and  hepatitis  may 
begin  in  the  same  way,  so  that  we  can  only  feel  sure  of  our  diag- 
nosis after  waiting  a  little  while.  If  the  gastralgic  pains  in  gastritis 
are  unusually  severe,  but  only  moderately  developed  in  biliary  colic, 
the  accompanying  gastro-duodenal  catarrh  well  marked,  while  jaun- 
dice is  absent,  and  where  possibly  some  fruit  seeds  in  the  stool  may 
be  mistaken  for  gallstones — in  such  a  case  the  diagnosis  may  remain 
doubtful,  unless  the  characteristic  sensitiveness  in  the  right  hypo- 
chondrium  helps  us  out.  However,  these  difiiculties  occur  more 
frequently  on  paper  than  they  do  in  practice,  and  diagnostic  errors 
here  are  of  still  less  importance, -since  the  rapid  course  of  the  disease 
reveals  the  true  condition. 

Treatment  of  Acute  Gastric  Catarrh. — If  it  be  true  that  this  dis- 
ease never  occurs  spontaneously,  but  is  always  caused  by  some  irri- 
tation introduced  from  without,  and  that  after  its  removal  the 
inflamed  mucous  membrane  rapidly  returns  to  the  normal,  the  in- 
dications for  treatment  can  only  be  to  remove  any  noxious  substances 
and  to  prevent  any  further  disturbance — in  other  words,  to  spare 
the  organ.  But  even  this  the  stomach,  as  a  rule,  does  for  itself. 
The  vomiting  and  the  anorexia  are  l^ature's  cure,  which  will  act 
promptly  provided  it  is  not  hindered  by  overzealous  physicians.  I 
do  not  even  consider  it  necessary  to  use  the  mild  vegetable  aperi- 
ents, especially  the  favorite  emulsion  of  castor  oil,  for  as  a  rule  the 
bowels  move  spontaneously,  and  the  fat  of  the  castor  oil  can  simply 
irritate  the  stomach  still  more.  Under  such  circumstances  it  is 
much  better  to  give  a  Brausepuhier^  or  some  effervescing  citrate  of 

*  [The  Brausepulver  (Ph.  Germ.)  consists  of  sodium  bicarbonate  10  parts,  tar- 
taric acid  9  parts,  white  sugar  19  parts.     Mix  thie  well-dried  powders. — Ed.] 


SIMPLE  ACUTE  GASTRITIS.  177 

magnesia,  or  a  Seidlitz  powder ;  furthermore,  a  fast  of  twenty-four 
or  even  seventy-two  hours  is  absolutely  necessary,  and  it  is  only  to 
be  broken  on  the  appearance  of  a  feeling  of  real  hunger.  Few 
things  are  more  foolish  than  the  popular  notion  that  "  we  must  oif er 
something  to  the  stomach"  or  "you  can't  live  two  days  without 
eating,"  for  the  public  ought  to  have  learned  that  a  man  can  easily 
live  for  a  day  or  two  on  his  own  fat  from  the  example  of  the  cele- 
brated fasters  of  the  past  few  years. 

We  should  only  attempt  to  empty  the  stomach  artificially  when 
spontaneous  vomiting  has  not  occurred,  and  pressure,  fullness,  pains, 
and  dullness  over  the  stomach,  as  well  as  the  belching  of  foul-smell- 
ing gases,  show  that  the  vise  us  is  still  full,  and  that  the  natural  re- 
sources of  the  organism  are  not  adequate  to  empty  it  either  by  the 
mouth  or  the  bowels.  The  simplest  and  best  method  is  to  let  the 
patients  drink  considerable  quantities,  say  |-  to  f  litre  [quart],  of 
warm  salt  water,  and  then  to  tickle  the  back  of  the  throat  with  a 
feather  or  the  finger  ;  where  these  fail  the  tube  should  be  intro- 
duced. As  a  result  the  patients  vomit  after  this,  and  we  thus  avoid 
causing  them  any  more  disgust  or  producing  fresh  irritation  of  the 
stomach  by  the  use  of  specific  emetics.  Otherwise  the  best  reme- 
dies are  a  dose  of  apomorphia,  0"25  to  0'50  centigramme  [gr.  ^^ 

to  yV],  or 

;^    Pulv.  ipecac 1-5     [gr.  xxiij] 

Antimon.  et  potass,  tartrat 0*05  [gr.  |-] 

M.  Ft.  chart,  no.  j.  Sig.  :  To  be  taken  at  once  or  in  divided 
doses.  In  children  we  may  give  a  teaspoonful  of  sirup  of  ipecac. 
Should  constipation  continue  after  the  first  two  days,  prompt  action 
can  be  obtained  by  administering  some  carbonate  of  magnesia  in  the 
form  of  an  effervescing  lemonade,  or  a  teaspoonful  of  compound  lico- 
rice powder,  or  a  glass  of  Hunyadi  water.  In  such  cases  I  am  very 
fond  of  using  calomel,  given  once  or  not  too  frequently  repeated,  and 
regret  that  with  us  in  Germany,  irrespective  of  its  use  in  children's 
diseases,  it  is  not  prized  as  highly  as  it  is  in  England.  It  possesses 
so  many  advantages — its  mild  purgative  effect,  its  cholagogue  prop- 
erties, its  disinfecting  action  (since  it  is  converted  into  corrosive  sub- 
limate)— ^tliat  the  idiosyncrasy  of  its  easily  causing  salivation  in  rare 
cases  can  by  no  means  outweigh.     In  adults  it  must  not  be  given  in 


1Y8  DISEASES  OP  THE  STOMACH. 

too  small  doses,  about  0*4  [gr.  vj]  repeated  in  an  hour  ;  *  it  may  ad- 
vantageously be  combined  with  small  quantities  of  aloes  (0"1  [gr.  jss.] 
of  the  extract)  or  colocynth  (0-01  [gr.  ^]  of  the  extract).  The  decoc- 
tions of  cortex  frangula  and  also  of  senna,  which  have  been  recom- 
mended, cause  much  more  discomfort  and  pain  in  acute  gastro-duo- 
denal  catarrh  than  in  chronic  cases.  Should  marked  pyrosis  exist,  it 
is  advisable  to  follow  the  old  practice  of  using  alkalies  to  neutralize 
the  acids  which  have  been  formed ;  the  best  of  these  is  bicarbonate 
of  soda ;  possibly  the  generated  carbonic-acid  gas  has  the  same  re- 
freshing and  stimulating  effect  upon  the  mucous  membrane  as  it  has 
elsewhere ;  or  perhaps — and  this  seems  to  me  to  be  much  more 
probable — the  well-known  good  effect  is  due  to  the  anaesthetic 
action  of  this  gas  which  was  demonstrated  by  Brown-Sequard.  In 
these  cases  it  is  not  advisable  to  give  magnesia  usta,  for  the  caustic 
magnesia  is  quite  insoluble. 

Gastritis  sympathica  acuta  is  an  exceedingly  frequent  accompani- 
ment of  numerous  acute  febrile  disorders.  All  the  exanthematous 
infectious  diseases — smallpox,  measles,  scarlatina,  typhus  and  ty- 
phoid fevers — the  croupous  and  diphtheritic  processes,  dysentery, 
pyaemia,  and  puerperal  fever,  may  have  disturbance  of  the  gastric 
functions  associated  with  them.  We  can  directly  prove  that  not 
only  are  they  due  to  reflex  nervous  action  (for  instance,  the  influ- 
ence of  fever  on  the  gastric  juice  proved  by  Hoppe-Seyler  f  and 
Manassein :{:),  but  also  that  they  directly  alter  the  mucous  mem- 
brane. However,  I  must  add  that  this  effect  of  fever  on  the  secre- 
tion and  composition  of  the  gastric  juice  is  by  no  means  always 
present.  It  is  true  that  I  have  myself  published  *  some  results  of 
my  own  which  agree  with  Manassein,  that  the  gastric  juice  of 
febrile  patients  digests  more  slowly  than  that  of  healthy  persons, 
yet  Sassezki  ||   found  that  in  fever  patients  without  marked  dys- 

*  [By  using  reliable  tablet  triturates,  small,  frequently  repeated  doses  up  to  0-15 
[gr.  ij]  will  usually  be  ample.  The  combination  of  calomel  and  bicarbonate  of  soda, 
which  has  been  recommended  to  prevent  salivation  and  to  lessen  the  griping,  will 
be  found  valuable. — Ed.] 

^  Hoppe-Seyler.    Allgemeine  Biologie,  1877,  S.  243."         t  Manassein,  loe.  cit. 

*  Ewald.     Klinik,  etc.,  I.  Theil,  3te  Auflage,  S.  128. 

II  Sassezki.  Ueber  den  Magensaft  Fiebernder.  Petersburger  med.  Wochenschr., 
1879,  No.  19. 


SYMPTOMATIC   ACUTE   GASTRITIS.  1Y9 

jDepsia  there  was  no  diminution  in  the  digestive  power.  That  the 
secretion  of  hydrochloric  acid  need  not  be  specially  changed  has 
been  proved  by  Edinger  *  in  five  cases  of  fever  (phthisis,  recurrent, 
intermittent,  and  typhoid  fevers),  Klemperer  f  and  Schetty  :|:  have 
made  similar  observations  in  phthisical  patients  with  fever.*  Re- 
cently I  used  the  test  breakfast  on  the  fourth  and  fifth  day  of  fever 
in  a  young  woman,  twenty -seven  years  old,  who  had  facial  ery- 
sipelas with  a  febrile  movement  up  to  39°  to  40-5°  C.  [102-5°  to 
104*9°  Fahr.].  Although  the  acidity  was  low — namely,  24  and  36 
respectively — yet  free  HCl  was  present,  the  digestion  test  with  the 
filtered  stomach  contents  took  the  usual  time,  and  a  retardation  of 
the  gastric  digestion  could  only  be  recognized  by  the  presence  of 
an  amount  of  propeptone  somewhat  larger  than  usual.  Up  to  that 
time  the  patient  had  received  no  medicines.  Her  general  condition 
was  good,  with  the  exception  of  prostration,  loss  of  appetite,  and 
the  local  trouble.  On  examining  the  stomach  ten  days  later,  when 
the  patient  was  fully  convalescent,  I  found  the  acidity  to  be  32  and 
the  other  chemical  functions  the  same  as  before.  It  must  remain  a 
matter  of  doubt  whether  the  average  normal  acidity  in  this  case 
might  not  be  somewhat  higher,  for  I  did  not  have  another  oppor- 
tunity of  repeating  the  examination.  At  all  events,  this  case  proves 
that  even  with  high  fever  the  gastric  juice  need  not  be  specially 
altered,  and  that  therefore  the  temperature  jf^r  se  neither  directly 
nor  indirectly  influences  the  glands  of  the  stomach. 

This  is  an  additional  reason  for  assuming  an  actual  change  in 
the  mucous  membrane  in  the  above-mentioned  sympathetic  dis- 
orders of  the  stomach.  Although  the  gastric  symptoms  are  rele- 
gated to  the  background  by  the  other  manifestations,  yet  in  those 
cases  with  dyspeptic  disturbances  in  which  we  are  enabled  to  ex- 
amine the   organ  soon  after  death,  we  will   find   the  anatomical 


*  L.  Edinger.  Zur  Physiologie  und  Pathologie  des  Magens.  Deutsch.  Arch, 
fiir  klin.  Med.,  Ed.  xxix.  S.  555. 

f  G-.  Klemperer.  Ueber  Dyspepsie  der  Phthisiker.  Berlin,  klin.  Woehensehr., 
1889,  No.  11. 

X  F.  Schetty.  Untersxiclmng  liber  die  Magenfunction  bei  Phthisis.  Deutsch. 
Arch.  f.  klin.  Med.,  Bd.  xliv.  S.  219. 

*  [See  also  W.  S.  Penwick.  The  Dyspepsia  of  Phthisis.  London,  1894,  p.  126, 
—Ed.] 


180  DISEASES   OP   THE   STOMACH. 

changes  of  acute  gastritis.     [This  has  since  been  corroborated  by 
Cohnheim  and  Hay  em.] 

In  diphtheria,  variola,  and  scarlatina  even  false  membranes  and 
diphtheritic  nlcers  may  be  formed.*  According  to  Smirnow,  we 
must  here  deal  with  two  forms  of  the  disease.  In  the  one  form 
there  is  a  more  or  less  marked  hypersemia  with  extras- asation  and 
desquamation  of  the  glandular  epithelium  without  any  disturbances 
of  the  true  secretory  parenchyma — i.e.,  a  fibrinous  inflammation;' 
in  the  other,  the  mucous  membrane  itself  is  attacked  by  a  necrobi- 
otic  process  and  passes  into  the  condition  described  by  Yon  Reck- 
linghausen as  hyaline  degeneration  of  the  cellular  elements.  In 
addition,  Kalmus  claims  to  have  found  numerous  bacteria  not  only 
in  the  exudate  and  necrotic  tissue,  but  also  in  the  depths  of  the  still 
sound  tissues,  and  even  in  the  subnmcosa ;  while  Smirnow,  as  stated 
above,  found  the  tissues  entirely  free  from  them.  Kalmus  found 
gastric  diphtheria  in  6*5  per  cent  of  his  cases  (199).  The  site  of  the 
diphtheritic  ulcers  is  usually  at  the  cardia,  whence  they  spread  in 
radiating  lines  toward  the  fundus.  In  other  cases  we  find,  especially 
at  the  fundus,  small  yellowish  or  brownish  sloughs  surrounded  by  a 
reddened  zone,  or  even  membranes  which  consist  of  fibrin,  mucus, 
desquamated  glandular  cells  and  their  products  of  disintegration,  or 
which  may  be  partly  of  an  exudative  character.  When  they  are 
cast  off  they  leave  deep  losses  of  substance  behind,  and  are  accom- 
panied by  necrosis  of  the  layers  of  the  mucous  membrane ;  they 
may  also  cause  fatal  haemorrhages.  This  process  is  naturally  much 
more  than  a  simple  acute  gastritis ;  furthermore,  even  if  they  do 
not  have  such  severe  results,  the  acute  inflammation  accompanying 
the  above-mentioned  diseases  easily  assumes  a  chronic  form,  and  may 
therefore  persist  long  after  the  primary  disorder  has  subsided,  and 
thus  delay  convalescence. 

Acute  gastritis  may  become  subacute  or  chronic.     The  assertion 
that  a  subacute  catarrh  is  always  developed  from  an  acute  attack 


*  Cahn.  Ein  Fall  von  Gastritis  diphtheritica  bei  Rachendiphtherie  mit  acuter 
gelber  Leberatrophie.  Deutsch.  Arch,  fur  lilin.  Med.,  Bd.  xxxiv,  S.  113. — G.  Smir- 
now. Ueber  Gastritis  raembranacea  und  diphtheritica.  Vireh.  Arch.,  Bd.  cxiii,  S, 
356.— G.  Kalmus.  Ein  Beitrag  zur  Statistik  und  pathologischen  Anatomic  der 
secundare  Magendiphtheritis.     Inaug.  Dissertation.     Kiel,  1888. 


PHLEGMONOUS  GASTRITIS.  181 

can  onlj  be  accepted  with  a  reservation.  Many  cases  undoubtedly 
run  a  subacute  form  at  first,  and  become  acute  after  some  severe 
irritation. 

The  French  very  appropriately  designate  subacute  catarrh  em- 
barras  gastrique,  the  English  call  it  indigestion,  while  in  Germany 
it  is  described  as  status  gastricus.  Its  symptoms  and  treatment  are 
so  closely  connected  with  chronic  gastritis  that  their  discussion  may 
be  deferred  to  the  chapter  on  the  latter. 

Suppurative  Inflammatioii  of  the  Stomach;  Gastritis  Phle^onosa 
Purulenta. — This  lesion,  which  is  usually  acute  and  rarely  subacute, 
differs  from  acute  gastritis  in  the  fact  that  it  is  not  situated,  lihe 
the  latter,  on  the  glandular  layer  of  the  stomach,  but  in  the  sub- 
mucosa  and  muscularis.  The  condition  is  rare,  and  I  can  only  re- 
call one  case  of  a  female  servant  whom  I  saw  at  Frerichs's  clinic. 
Quite  a  number  of  such  cases  have  been  published,  especially  of 
late,  after  Andral  and  Cruveilhier,  Rokitanski  and  Dittrich,  Ha- 
bershon,  Brinton  [and  Heintz  *]  had  described  and  classified  them ; 
hence  it  is  not  difficult  to  obtain  a  complete  description  of  the 
disease. 

Occurrence  and  Etiology. — Men  seem  to  be  especially  liable.  Of 
Lebert's  31  cases,  26  were  men  and  5  women.  According  to  Glax,f 
the  number  of  cases  published  since  then  (1878)  would  increase  the 
total  to  51 :  41  of  these  include  33  men  and  8  women.  It  occurs 
most  frequently  between  the  twentieth  and  sixtieth  years. 

We  may  distinguish  an  idiopathic  prima/ry  and  a  metastatic 
form. 

The  causes  of  primary  phlegmonous  gastritis  are  unknown ;  at 
least  I  can  not  attribute  any  importance  to  the  vague  claims  for 
alcoholism,  dietetic  errors,  traumatisms,  etc.  It  is  just  here,  if  any- 
where in  the  whole  field  of  the  diseases  of  the  stomach,  that  we 
can  assume  that  the  disease  is  due  to  infection,  and,  in  accordance 
with  our  present  knowledge,  to  bacteria.     In  fact,  Ziegler  :|:  claims 

*  [Heintz.     Deutsch.  Arch,  flir  klin.  Med.,  1892,  Bd.  xlix,  p.  487.— Ed.] 
f  J.  Glax.    Die  Magenentziindung.     Deutsch.  med.  Zeitung,  1884,  No.  3. 
X  Ziegler.     Lehrbuch  der  allgemeine  and  spec,  pathologische  Anatomie,  1887 
[Bd.  ii],  S.  516. 


182  DISEASES   OP   THE  STOMACH. 

to  have  found  numerous  streptococci  partly  free  in  tlie  tissues  and 
partly  inclosed  in  the  cells. 

A  second  form  is  the  metastatic,  which  occurs  in  severe  pysemic, 
puerperal,  and  exanthematous  diseases,  or  is  due  to  an  extension  of 
a  perigastric  phlegmon.  Here  we  may  also  include  the  phlegmo- 
nous abscesses  which  are  due  to  some  ulcerated  condition  of  the 
gastric  mucosa,  which  resemble  phlegmonous  inflammation  of  the 
stomach.  Thus  Thoman  *  has  reported  the  case  of  a  sixty-year-old 
woman  who  had  had  two  violent  attacks  of  severe  febrile  gastralgia 
with  inflammatory,  tumorlike  induration  of  the  epigastrium,  and 
later  died  of  haematemesis.  Lindemann  f  treated  a  woman  who 
had  several  teeth  extracted.  This  was  followed  by  ulcerative  in- 
flammation of  the  mouth,  with  intensely  infectious  secretion. 
Shortly  after  this  she  was  attacked  with  a  diifuse  phlegmonous 
gastritis. 

Pathological  Anatomy. — Circumscribed  abscesses,  gastritis  phleg- 
monosa  circumscripta,  also  called  abscess  of  the  stomach,  must  be 
differentiated  from  diffuse  purulent  infiltration.  As  a  rule  the  ab- 
scesses are  small,  varying  in  size  from  a  pea  to  a  hazel-nut ;  some- 
times they  are  as  large  as  a  walnut  or  goose-egg.  The  mucous 
membrane  is  raised  over  these  areas,  and  on  cutting  into  it  we  find 
that  the  abscesses  are  in  the  submucosa,  possibly  infiltrating,  and 
causing  purulent  liquefaction  of  the  muscularis  and  extending  down 
to  the  serosa.  In  advanced  stages,  perforation  may  occur  into  the 
cavity  of  the  stomach  or  peritonaeum.  The  diffuse  infiltration  ad- 
vances in  the  submucous  tissue  and  extends  up  between  the  glandu- 
lar tubules  of  the  mucosa  or  along  the  bundles  of  muscular  fibers 
in  the  muscularis  ;  the  muscle  fibers  themselves  undergo  fatty  de- 
generation or  show  proliferation  of  the  nuclei  and  infiltration  with 
pus  cells.  Cribriform  perforations  of  the  surface  of  mucous  mem- 
brane now  occur,  through  which  pus  wells  up  on  pressure ;  or  the 
pus  penetrates  down  toward  the  serosa,  separates  and  perforates  it, 
unless  adhesions  with  the  adjacent  viscera  have  been  formed  as  the 
result  of  preceding  inflammation. 

*  Thoman.      Inflaminatio  phlegmonosa  ventrieuli ;   ulcus  perforans ;   htemate- 
mesis ;  death.     Allgemeine  Wiener  Zeitung,  1891,  No.  10. 

f  Lindemann,  quoted  by  Joh.  Meyer,  Petersburg,  med.  Wochensch.,  1892,  No.  40. 


PHLEGMONOUS  GASTRITIS.  183 

Symptoms. — In  the  majority  of  cases  the  disease  runs  an  acute 
or  even  foudroyant  course ;  a  chronic  form  is  very  rare  indeed. 
The  onset  is  either  sudden,  as  in  the  case  observed  by  me,  or  it 
may  be  preceded  by  vague  dyspeptic  disturbances  ;  it  is  marked  by 
exceedingly  violent  and  intense  pain  in  the  epigastrium,  severe 
burning  in  the  stomach,  raging  thirst,  dry  tongue,  and  complete 
anorexia.  From  the  beginning  the  patients  feel  that  they  are  very 
ill ;  high  fever  at  once  sets  in,  the  temperature  reaching  40°  C. 
[104:°  r.]  or  more,  with  occasional  chills  and  slight  remissions.  The 
pulse  is  small,  frequent,  or  irregular.  Emesis  is  rarely  absent ;  the 
vomit  consists  of  biliary  or  mucous  masses  or  large  quantities  of 
pus.*  The  sensorium  is  always  severely  affected  ;  the  patients  are 
restless  and  anxious.  In  one  case  observed  by  Lebert  this  con- 
dition was  so  marked  that  the  sufferer  threw  himself  out  of  a  win- 
dow and  died  at  once.  Dehrium  may  now  appear,  and  the  patient 
dies  in  coma  or  in  general  prostration.  It  is  not  surprising  that  such 
a  clinical  picture  should  resemble  acute  articular  rheumatism,  and 
indeed  we  find  the  following  case  described  by  Macleod  :  f 

A  laborer,  thirty-six  years  old,  was  ill  for  a  fortnight,  apparently  from 
acute  articular  rheumatism.  No  pain  in  the  epigastrium,  no  vomiting. 
Delirium  and.  great  restlessness  were  attributed  to  alcoholism.  Died 
comatose.  The  autopsy  showed  that  the  wall  of  the  stomach  in  the  vicin- 
ity of  the  greater  curvature  and  pylorus  was  1"5  centimeters  [f  inch]  thick 
and  contained  large  quantities  of  yellow  pus  between  the  muscularis  and 
submucosa.  The  mucosa  was  unchanged.  There  was  no  inflammation 
of  the  joints  or  any  other  suppurative  processes. 

A  case  published  by  Joh.  Meyer  %  shows  that  the  development 
of  a  hepatic  tumor  may  cause  displacement  of  the  heart  and  com- 
press the  lungs  by  pushing  the  diaphragm  upward,  and  may  thus 
simulate  a  subphrenic  abscess. 

Grainger  Stewart  has  observed  inflammation  and  gangrene  of 
the  gall-bladder.*     W.  Lewin  ||  has  seen  petechise  over  the  entire 

*  Bukler.  Idiopathiseh-plegmonose  Gastritis.  Bayer,  arztliches  InteUigenz- 
blatt,  1880,  No.  37. 

f  Macleod.  Suppurative  Gastritis ;  Death ;  Necropsy.  Lancet,  1887,  vol.  ii,  p. 
1166. 

X  Joh.  Meyer.  Ein  Fall  von  idiopathischen  Magenabscess  and  ein  Fall  von 
subphrenischen  Abscess.     Petersburg,  med.  Wochenschr.,  1893,  No.  40. 

*  Edinburgh  Med.  Journal,  February,  1868. 

I  W.  Lewin.    Berl.  klin.  Wochenschr.,  1884,  S.  73. 
13 


184  DISEASES  OF  THE  STOMACH. 

body,  tliose  on  the  right  thigli  reacliuig  the  size  of  a  hazel-nut ; 
there  was  also  jaundice.  The  autopsy  revealed  multiple  abscesses 
between  the  mucosa  and  serosa  of  the  stomach,  diffuse  purulent 
peritonitis,  and  suppurative  pleurisy  on  the  left  side.  Brinton  and 
Chvosteck*  have  also  found  jaundice  in  idiopathic  phlegmonous 
gastritis  ;  it  might  perhaps  be  explained  by  the  extension  of  the  in- 
flammation to  the  duodenum  and  the  mouth  of  the  common  bile 
duct,  unless  it  is  a  pysemic  icterus.f  Glaser  reports  the  very  rare 
occurrence  of  this  disease  in  the  course  of  a  carcinoma  and  an  ulcer 
of  the  stomach.  In  these  two  cases,  strange  to  say,  vomiting,  which 
is  otherwise  so  constant,  was  absent.  [Mintz  has  also  reported  it 
after  cancer  of  the  stomach.] 

During  the  course  of  the  disease  there  is  either  absolute  consti- 
pation, or,  what  is  more  common,  diarrhoea  occurs  with  marked 
meteorism  and  gargouillement.  The  duration  is  two  weeks  at  the 
utmost,  but  it  generally  lasts  a  much  shorter  time.  Lewin's  case, 
quoted  above,  which  lasted  four  weeks,  is  an  exceedingly  rare  ex- 
ception. 

Diagnosis. — It  will  be  seen  from  the  clinical  picture  that  in  the 
majority  of  cases  the  diagnosis  of  this  disease  can  only  be  a  matter 
of  chance  ;  for,  on  the  one  hand,  the  process  so  closely  resembles  a 
circumscribed  peritonitis,  and,  on  the  other,  perigastric  inflamma- 
tions or  abscess  formation  may  give  rise  to  such  confusingly  similar 
symptoms — e.  g.,  arteritis  or  abscess  of  the  left  lobe  of  the  liver  or 
of  the  spleen — that  a  differential  diagnosis  is  absolutely  impossi- 
ble. The  case  quoted  above  has  also  led  Joh.  Meyer  to  accept  this 
view. 

I  can  not  agree  with  Deininger  ^  in  considering  that  high  tem- 
perature, constant  pain  in  the  stomach  which  is  not  increased  on 
movement,  and  increased  resistance  in  the  epigastrium,  are  suffi- 
ciently characteristic  points  on  which  to  base  a  diagnosis  ;  and  it  is 
my  opinion  that  the  doubts  of  the  possibility  of  establishing  a  diag- 
nosis, already  expressed  in  1879  by  Leube,  have  not  been  removed 
by  the  cases  which  have  since  been  published.     Even  if  large  quan- 

*  Wiener  Klinik,  1881,  and  Wiener  med.  Presse,  1877,  Nos.  22-29. 

t  Berl.  klin.  Wochenschrift,  1883,  S.  790. 

X  Deutsch.  Arehiv  f.  klin.  Med.,  Bd.  xxi,  S.  628. 


PARASITIC   GASTRITIS.  185 

tities  of  pus  should  be  vomited,  and,  as  happened  in  a  case  of  Cal- 
low and  also  of  Deininger,  a  previously  palpable  tumor  should  dis- 
appear after  such  vomiting,  the  presence  of  a  gastric  phlegmon 
could  not  be  positively  asserted.  The  differential  diagnosis  from 
typhus  fever  which  it  might  resemble  in  its  febrile  movement  and 
the  possible  occurrence  of  petechiae,  might  more  readily  be  made 
by  the  violent  and  continuous  pain. 

Treatment  can  only  be  symptomatic — i.  e.,  antiphlogistic.  Cold 
applications  to  the  abdomen,  possibly  the  use  of  leeches,  swallowing 
pieces  of  ice,  ice-cold  effervescing  mixtures,  hypodermic  injections 
of  morphine,  and  restoratives,  are  the  only  means  at  our  disposal  in 
such  cases. 

Parasitic  Gastritis — Gastritis  Mykotica  et  Parasitaria. — The  little 
we  know  about  the  invasion  of  the  mucous  membrane  of  the  stom- 
ach by  fungi  may  fittingly  be  discussed  in  connection  with  gastric 
phlegmon. 

I  know  of  only  one  case  of  the  invasion  of  the  grosser  fungi, 
namely,  that  reported  by  Kundrat  *  of  a  drunkard  with  f avus  uni- 
versalis, in  which  the  parasites  had  even  penetrated  as  far  as  the 
mucous  membrane  of  the  stomach  and  intestines.  Here  the  fungi 
had  caused  a  diphtheritic  inflammation  with  ulceration  and  slough- 
ing and  fibrinous  exudations.  Kundrat  thinks  that  the  mucous 
membrane  was  predisposed  by  the  drunkard's  chronic  catarrh. 
Death  was  due  to  diarrhoea  which  resisted  all  treatment.  [The 
fungus  of  thrush,  oidium  albicans,  may  also  be  found  in  the  stom- 
ach ;  a  case  of  this  kind  has  been  reported  by  Rosenheim.f  ] 

Some  time  ago  Klebs;]:  described  a  hacillus  gastricus  which 
occurred  in  a  number  of  cases ;  it  had  numerous  spores,  and  was 
found  free  in  the  lumen  of  the  glands  as  well  as  between  the  mem- 
brana  propria  and  the  epithelium  of  the  latter.  Unfortunately,  we 
have  learned  nothing  of  the  chnical  features  of  these  cases.     Oi-th  * 

*  Kundrat.    TJeber  Gastroenteritis  favosa,     Wien.  med.  Blatter,  1884,  No.  49. 

f  [Rosenheim.  Krankheiten  des  Speiserohre  und  des  Magens.  2te  Aufl.,  1896, 
p.  236.— Ed.] 

X  Klebs.  Ueber  infectiose  Magenaffectionen.  AUgemeine  Wiener  med.  Zei- 
tung,  1881,  Nos.  29,  30. 

*  J.  Orth.     Lehrbuch  der  spec,  patbolog.  Anatomie,  1887,  S,  704. 


186  DISEASES  OF  THE  STOMACH. 

reports  a  case  of  gastric  ulcer  in  wliicli  there  were  gray  sloughs  of 
the  mucous  membrane  looking  like  bran  and  containing  bacilh. 
[Martin*  believes  that  bacterial  necrosis  plays  an  important  part 
in  the  formation  of  many  ulcers  of  the  stomach.  Nauwerck  f  also 
asserts  that  capillary  mycotic  emboli  may  cause  gastric  ulcers. 
(See  Chapter  YIII.)  The  occurrence  of  bacilh  in  gastric  cancer 
will  be  discussed  in  Chapter  YII.] 

E.  Frankel :{:  has  reported  a  case  of  emphysematous  gastritis 
which  was  probably  of  mycotic  origin. 

A  laborer,  thirty -five  years  old,  sustained  a  severe  contusion  of  the 
right  hand,  with  crushing  of  the  last  phalanx  of  the  index  finger.  Under 
appropriate  surgical  treatment  the  patient  did  very  well ;  but  on  the  sev- 
enth day  he  suddenly  went  into  collapse,  complained  of  pain  in  the 
stomach,  and  vomited  bloody  masses.  In  spite  of  the  excellent  condition 
of  the  wound,  which  in  no  way  corresponded  to  the  severity  of  the  gen- 
eral condition,  the  symptoms  persisted  two  days  longer,  when  the  patient 
died  in  collapse. 

At  the  autopsy  it  was  found  that  the  mucous  membrane  of  the  stomach 
was  of  an  intense  red  color,  and  was  dotted  with  numerous  bubbles  of  air 
which  had  been  formed  between  the  mucosa  and  the  submucosa.  There 
were  neither  extravasations  of  blood  nor  losses  of  substance,  either  of 
short  or  long  standing.  Processes  of  putrefaction  were  also  absent.  Mi- 
croscopic examination  of  the  tissue  surrounding  the  bubbles  revealed 
numerous  bacteria,  resembling  those  of  anthrax.  They  were  not  found 
within  the  glands  of  the  stomach  or  blood  vessels.  This  tissue  also  had 
foci  of  infiltrations  with  small  cells,  its  vessels  were  filled  to  distention, 
and  there  were  also  microscopic  extravasations  of  blood. 

Frankel  properly  rejects  the  supposition  that  the  process  was 
one  of  putrefaction  or  the  invasion  of  bacteria  from  the  free  surface 
of  the  gastric  mucous  membrane ;  he  attributes  it  to  an  involve- 
ment of  the  gastric  mucosa  by  bacilh  which  had  probably  entered 
the  circulation  through  the  wound,  but  had  not  caused  any  infection 
at  this  point  of  entry. 

Thus  far  the  clearest  of  all  have  been  the  troubles  caused  by 
anthrax,  in  which  the  bacilli,  as  Orth  says,  "  reach  the  stomach 
either  as  such,  or  as  spores  from  without  or  from  the  blood."  They 
cause  marked  swelling  of  small  areas  of  the  mucous  membrane,  and 

*  [Martin.     Diseases  of  the  Stomach.     London,  1895.  p.  418. — Ed.] 
\  [Nauwerck.     Miinch.  med.  Wochenschr.,..  1895,.  No.  39. — Ed.] 
X  E.  Frankel.    Virchow's  Archiv,  Bd.  cxviii,  p.  536. 


PARASITIC  GASTRITIS.  187 

especially  of  the  submucosa,  witli  central  sloughing  and  consecutive 
ulceration. 

The  bacteria  found  in  diphtheria  of  the  gastric  mucosa  hare 
already  been  mentioned  (page  180). 

I  must  also  mention  the  occurrence  of  sarcinae,  yeast  cells, 
numerous  fungi,  etc. ;  they  may  at  times  grow  very  luxuriantly  and 
irritate  the  mucous  membrane  by  their  products,  yet  they  never 
seem  to  penetrate  into  it.  Thus  in  the  stomach  contents,  and  espe- 
cially in  the  tenacious  mucus  which  adheres  to  the  mucosa,  we  may 
find  numerous  micro-organisms,  and  especially  sarcinse,  bacterium 
lactis,  a  bacillus  butyricus,  and  numerous  other  organisms,  and  yet 
we  can  not  find  a  single  organism  in  or  between  the  gastric  tubules. 
Abelous,"*  who  has  made  a  very  thorough  study  of  the  organisms  of 
the  stomach  contents,  and  who,  for  example,  isolated  no  less  than 
eight  different  bacilli,  also  makes  no  mention  of  any  invasion  of  the 
mucous  membrane.  [The  researches  of  Kaufmann,  Macfadyen, 
Strauss,  and  Bial  have  already  been  referred  to.] 

On  the  other  hand,  I  may  add  concerning  foreign  parasitic 
organisms,  even  if  they  are  not  mycotic,  that  Gerhardt  f  reports  an 
acute  gastritis  which  was  due  to  the  invasion  of  larvse  of  dipteree 
which  were  probably  swallowed  with  raspberries,  and  that 
Meschede :{:  has  seen  the  same  disease  caused  by  maggots  in  cheese. 
On  the  other  hand,  Lubhnski*  found  that  no  special  effect  was 
produced  by  larvae  of  the  house  fly  which  had  been  swallowed  in 
raw  meat  and  got  rid  of  by  vomiting.  Senator  and  Hildebrandt  || 
have  reported  similar  cases.  In  Senator's  cases  the  larvse  were  not 
alone  vomited,  but  came  up  spontaneously  and  were  spat  out  by  the 
patient  or  removed  from  the  mouth  with  his  finger.  A  long  time 
ago  Fermaud  ^  observed  a  somewhat  similar  case,  in  which  gastritis 

•  Abelous.     Recherches  sur  les  microbes  de  restomae.     Montpellier,  1889. 

f  C.  Gerhardt.  Magenkatarrh  durch  lebende  Dipterenlarven.  Jenaer  med.  Zeit- 
schrift.  Bd.  iii.  S.  522. 

X  Meschede,  Ein  Fall  von  Erkrankung.  hervorgerufen  durch  verschluckte  und 
lebend  im  Magen  vervreilende  Maden.    Virchow's  Archiv,  Bd.  xxxvi,  S.  300. 

'^  W.  Lublinski.  Ein  Fall  von  lebenden  Fliegenlarven  im  menschliehe  Ma- 
gen, etc.    Deutseh.  med.  Wochenschr.,  1885,  No.  44a, 

I  [Senator.  Ueber  lebende  Fliegenlarven  im  Magen  nnd  in  der  Mundhohle. 
Berl.  klin.  "Wochenschr.,  1890,  Xo.  7. — See  also  Hildebrandt.  Erbrechen  von  Flie- 
genlarven.    Ibid..  1890,  No.  19.— Ed.] 

^  Fermaud.     Observ.  sur  une  cardialgie  accompag.  de  svraptomes  de  gastrite 


188  DISEASES  OP  THE  STOMACH. 

and  gastralgia  were  caused  by  an  earthworm  in  the  stomacli.  It  has 
also  been  known  for  a  long  time  that  ascarides,  and  even  taenia,  may 
wander  into  the  stomach  and  cause  intense  catarrh  of  this  viscus. 
Nevertheless,  we  may  consider  unique  the  case  reported  by  Pom- 
per  *  of  a  young  girl,  ten  years  old,  in  whom  the  oxyuris  vermicu- 
laris  worms  crawled  up  the  oesophagus  and  could  be  seen  creeping 
up  on  the  tongue. 

Gastritis  Toxica. — I  can  only  give  a  short  review  of  those  poisons 
which  directly  affect  the  gastric  mucous  membrane.  The  com- 
monest are  alcohol,  phosphorus,  cyanide  of  potassium,  arsenic 
(Schweinf  urt  green),f  corrosive  subhmate,  chlorate  of  potash,  nitro- 
benzol,  concentrated  mineral  acids  (also  carbolic  acid),  and  caustic 
alkahes. 

After  Yirchow :{:  had  described  the  fatty  degeneration  of  the 
glandular  epithelium  in  an  interesting  series  of  investigations,  Eb- 
stein**  showed  what  influence  alcohol  and  phosphorus  have  upon 
the  stomach ;  he  also  discovered  the  very  important  fact  that  after 
ingestion  of  these  substances  (which  also  serve  as  prototypes  of  a 
number  of  drugs  with  a  similar  action)  the  macroscopic  changes 
may  be  comparatively  sHght,  while  the  finer  structure  of  the  glandu- 
lar layer  is  greatly  altered  ;  for,  while  macroscopic  examination 
showed  only  a  mild  hypersemia  and  slight  extravasations  of  blood, 
the  microscope  revealed  that  the  epithelium  of  the  vestibule  ( Yor- 
raum)  of  the  glands  and  the  glandular  cells  themselves  were  cloudy 
and  granular  and  had  partly  undergone  mucoid  and  fatty  degenera- 
tion, and  the  interglandular  tissue  was  infiltrated  with  small  cells. 
Thus  a  gastritis  glandularis  degenerativa  is  developed,  which  even  in 
favorable  cases  disappears  very  slowly,  and  which  explains  the  pro- 
tracted digestive  disturbance  remaining  after  phosphorus  poisoning 
and  the  influence  of  the  abuse  of  alcohol  on  the  stomach. 

The  corrosive  poisons  act  differently.  I  can  not  here  discuss 
the  classical  picture  of  poisoning  by  sulphuric,  hydrochloric,  and 

intense  reeonnaissant  pour  cause  la  presence  d'un  ver  terrestre  dans  restomac. 
Jour,  de  med.  pratique  de  Paris,  1836,  tome  vii,  p.  57. 

*  Poraper.  Beitrag  zur  Lehre  vom  Oxyuris  vermicularis.  Inaug.  Dissert.,  Ber- 
lin, 1875. 

f  [So-called  Paris  green.]  |  Loc.  cit.  *  Loc.  cit. 


TOXIC   GASTRITIS.  189 

oxalic  acids  or  the  caustic  alkalies ;  I  shall  only  recall  the  fact  that 
their  effects  vary  accordino^  to  the  quantity  taken  and  the  fullness  of 
the  stomach  and  the  nature  of  its  contents  previous  to  the  act  of 
swallowing  the  poison.  In  mild  cases  the  destroyed  tissue  is  imper- 
ceptibly cast  off  and  cicatrization  follows ;  in  severer  cases  the 
mucosa  and  submucosa  are  cauterized  and  converted  into  a  black 
slough,  the  muscularis  becomes  the  seat  of  a  serous  or  gelatinous  in- 
filtration, or  is  charred  down  to  the  serosa ;  then  there  is  perfora- 
tion of  the  stomach,  with  escape  of  its  contents  into  the  peritoneal 
cavity.  Metallic  poisons  usually  cause  a  general  inflammation  and 
hypersemia,  or  they  involve  localized  areas  with  superficial  necrosis. 
Excellent  illustrations  of  these  conditions  will  be  found  in  Lesser's 
Atlas.*  A  very  characteristic  case  of  cicatrization  after  corrosion 
by  sulphuric  acid  has  been  pictured  in  Kast  and  Rumpel's  Atlas.f 

The  symptoms  of  poisoning  naturally  vary  according  to  the  na- 
ture of  the  substance  taken :  if  it  be  one  of  the  group  of  caustic 
fluids,  its  effects  will  be  manifested  in  the  mouth,  pharynx,  and 
oesophagus.  But  the  acute  action  on  the  stomach  can  also  be  read- 
ily recognized  in  the  group  of  symptoms  in  poisoning ;  for  the 
sudden  onset  of  all  the  symptoms,  the  repeated  vomiting  which  can 
hardly  be  allayed,  the  vomit  mixed  with  bloody  mucus  or  pure 
blood,  the  intense  pain  in  the  stomach  which  is  increased  on  vomit- 
ing, the  profound  collapse,  the  change  in  the  features  and  cyanosis, 
the  cold  extremities  covered  with  clammy  sweat,  and  the  small 
pulse — all  these  give  rise  to  a  suspicion  of  the  true  condition,  which 
is  either  verified  by  the  patient's  statements  or  by  examining  the 
vomited  matter.  These  acute  poisonings,  if  not  fatal,  always  leave 
behind  a  long  illness  and  all  the  symptoms  of  severe  disturbance  of 
the  functions  of  the  stomach ;  these  disturbances  are  partly  caused 
directly  by  the  profound  changes  in  the  coats  of  the  stomach,  above 
all  ia  the  glandular  layer,  and  their  possible  ulceration,  partly  by 
the  results  of  cicatrization.  In  these  cases  the  mucosa  and  submu- 
cosa may  also  be  cast  off  in  shreds.  In  the  patient  observed  by 
Laboulbene,  a  piece  of  membrane  over  twice  the  size  of  the  palm 

*  A.  Lesser.     Atlas  der  gerichtlichen  Medicin.     Berlin,  Hirschwald,  18S-L 
t  Kast  und  Rumpel.     Pathologisch-anatomische   Tafeln,    Wandsbeck,   1893, 
Lieferunsr  1. 


190  DISEASES  OP  THE  STOMACH. 

of  the  hand  was  vomited  fifteen  days  after  swallowing  sulphuric 
acid. 

In  passing,  I  wish  to  state  that  an  apparent  improvement  in  the 
patient's  condition  soon  after  the  ingestion  of  the  poison  should  not 
tempt  us  to  at  once  give  a  good  prognosis.  Not  long  ago  I  lost  a 
strong  young  woman,  nineteen  years  old,  who  had  swallowed  sul- 
phuric acid ;  at  the  end  of  the  first  week  there  was  a  decided  im- 
provement ;  yet  a  few  days  later  she  became  so  weak  that  she 
soon  died.  In  the  chapter  on  chronic  gastritis  I  shall  consider  the 
other  group  of  chronic  poisoning. 

The  discussion  of  the  diagnosis  and  treatment  of  the  individual 
varieties  of  acute  poisoning  lies  beyond  my  province.  Yet  I  may 
be  permitted  to  make  the  general  remark  that  the  stomach  should 
be  immediately  emptied  with  the  tube  in  all  cases  which  are  not 
due  to  caustic  substances,  as  can  always  be  ascertained  by  inspecting 
the  mouth  and  pharynx.  I  decidedly  prefer  this  to  the  administra- 
tion of  emetics,  which  always  require  some  time  for  their  action, 
and  which,  especially  in  comatose  persons,  are  by  no  means  reliable. 
We  can  cleanse  the  stomach  much  more  thoroughly  by  repeated 
siphonage  than  by  means  of  an  emetic,  and  we  can  always  introduce 
the  tube,  even  in  deep  coma ;  a  piece  of  gas  tubing,  which  can  be 
found  almost  everywhere  at  the  present  time,  can  readily  be  impro- 
vised, as  I  have  already  announced  in  1875,*  in  my  report  of  a  case 
of  poisoning  with  oil  of  mirbane  (nitrobenzol) ;  according  to  my  ex- 
perience, the  only  difficulty  will  be  to  rapidly  make  a  funnel  through 
which  water  may  be  poured  into  the  tube.  I  have  even  got  along 
with  a  medicine  bottle  by  knocking  out  the  bottom  and  slipping 
the  tube  over  the  neck.  We  can  proceed  to  the  real  treatment 
after  the  stomach  has  been  thoroughly  washed  out.  It  is  seK- 
evident  that  the  tube  must  not  be  used  where  there  is  danger  of 
perforation  from  the  swallowing  of  caustic  substances  ;  here  we 
must  give  neutralizing  substances  in  solution.  Even  ia  poisoning 
by  acids  the  introduction  of  the  tube  will  seldom  be  necessary,  since 
the  unabsorbed  portion  of  the  acid  may  be  neutralized  by  means  of 
calcined  magnesia  suspended  in  water  (about  100  grammes  [  5  iij] 

*  Ewald,  Zwei  Falle  von  Nitrobenzoivergiftung.  Berl.  klin.  Wochenschr., 
1875,  S.  3. 


TOXIC  GASTRITIS.  191 

of  magnesia  to  500  c.  c.  [a  pint]  of  water),  which  forms  harmless 
compounds  with  hydrochloric,  sulphuric,  and  nitric  acids,  and  an  in- 
soluble salt  with  oxalic  acid.  But  in  addition  we  must  always  give 
alkalies,  preferably  very  soluble  sodium  salts,  in  order  to  prevent 
the  impoverishment  of  the  blood  in  these  metals.  The  caustic  alka- 
lies can  be  neutralized  with  solutions  of  tartaric  acid  (1  to  5  per 
cent),  vinegar,  or  lemon  juice. 


CIIAPTEK  Y. 

CHEONIC    GLANDTJLAE    GASTRITIS. — CHEONIC    CATAEEH    OF    THE 

STOMACH. 

In  the  course  of  time  chronic  glandular  gastritis  has  received  a 
variety  of  names  :  chronic  catarrh  of  the  stomach,  habitual  dyspep- 
sia, indigestion,  atony  of  the  stomach,  statxis  gastricus,  bradypepsia, 
[ySpaSi;?,  slow  ;  TriTrrco,  to  digest],  apepsia,  etc.*  This  abundance  of 
names  shows  that  different  processes  have  been  grouped  together 
under  the  above  designations.  Thus  Copland  includes  under  dys- 
pepsia a  clinical  picture  which  is  evidently  that  of  gastric  ulcer. 
Toddf  distinguishes  idiopathic  and  deuteropathic  dyspepsia,  and 
subdivides  the  former  into  functional  and  organic  varieties,  and  the 
latter  into  sympathetic  and  symptomatic  ;  besides  these  he  recog- 
nizes atonic,  inflammatory,  irritable,  and  follicular  gastric  dyspepsia. 
Ross :{:  has  three  great  groups  of  dyspepsias,  namely  :  (a)  inflam- 
matory, (J)  functional,  (c)  organic  ;  these  he  classifies  again  into  no 
less  than  nine  subdivisions. 

If  we  disregard  Broussais's  well-known  description  of  gastro- 
enterite,  which  for  a  long  time  exerted  a  powerful  influence  on  the 
conception  of  diseases  of  the  stomach  among  the  French,  we  find 
even  to  this  day  in  all  French  books  that  dyspepsia  embraces  a  large 
chapter.  It  may  be  interesting  to  note  that  the  term  dyspepsia  was 
first  used  by  Jean  de  Bovis  in  the  sixteenth  century.     To  be  sure. 


*  An  amusing  recital  of  these  various  names  may  be  found  in  Moliere's  Malade 
imaginaire : 

PuRGON :   Et  je  veux  qu'avant  quatre  jours  vous  deveniez  dans  un  etat  incurable. 

Argon  :  Ah  !    Misericorde  ! 

PuRGON :   Que  vous  tombiez  dans  la  bradypepsie,  dans  la  dyspepsia.  * 

Argon  :   Mr.  Purgon  ! 

PuRGON  :   De  la  dyspepsie,  dans  I'apepsie  ! 

f  Todd.    Cyclopsedia  of  Practical  Medicine,  article  Indigestion.     London,  1833. 

X  J.  Ross.     Practical  Remarks  on  the  Treatment  of  the  Various  Forms  of  Dys- 
pepsia.   Edinburgh  Medical  Journal,  September,  1855. 

193 


NOMENCLATURE  OF  CHRONIC  GASTRITIS.  193 

Damaschino  says,  "  La  dyspepsie  n^est  pas  une  entite  morhide,^^  * 
yet  dyspepsia  is  discussed  in  very  broad  terms,  and  we  find  dyspepsie 
fiatulente  acide,  essentielle,  etc.  ;  even  a  special  "  dyspepsie  des 
liquides  "  is  spoken  of  by  Chomel !  Coutaret  has  published  a  large 
octavo  volume  of  11Y6  pages  under  the  title  of  Dyspepsie  et  Ca- 
tarrhe  Gastrique  (Paris,  1890) ;  and  Germain  See,t  who  distinctly 
describes  dyspepsia  as  an  "  operation  chimique  defecteuse^^^  still 
clings  to  a  purely  symptomatic  classification,  and  divides  dyspepsias 
into  those  with  changes  in  the  chemical  functions  and  those  with 
mechanical  disturbances.  This  is  about  as  scientific  as  it  would  be 
to  write  a  chapter  on  dropsies,  although  we  had  long  ago  advanced 
from  a  symptomatic  to  an  anatomical  classification.  It  is  only  re- 
cently that  Dujardin-Beaumetz  X  took  a  decided  stand  against  this 
view  of  the  dyspepsias,  and  says  :  "  D'^ailleurs  cet  mot  de  la  dyspep- 
sia essentielle  est  appele  de  disparaitre  de  la  pathologie.  II  cache 
en  effet  notre  ignorance^ 

The  Germans  were  the  first  to  destroy  this  conception  of  dyspep- 
sia as  a  disease,  and  to  recognize  it  as  only  a  pathological  condition  ; 
therefore  Lebert  properly  excluded  the  chapter  on  dyspepsia  from 
his  treatise  on  the  diseases  of  the  stomach.  In  fact,  such  terms 
as  dyspepsia,  indigestion,  etc.,  are  merely  descriptive  of  a  functional 
disturbance  but  not  of  a  distinct  disease ;  and  hence  to-day  we  ought 
not  to  find  a  physician  who  considers  a  disturbance  of  digestion  as  a 
separate  disease. 

In  making  a  historical  review  of  this  chapter  in  the  works  of  the 
writers  in  this  field,  we  find  that  its  extent  gradually  becomes  smaller 
— in  other  words,  that  distinct  clinical  types  have  been  successively 
separated  from  this  large  group.  Thus,  to  give  only  two  examples, 
irritable  and  atonic  dyspepsias  are  now  included  under  the  gastric 
neuroses,  and  we  may  equally  well  class  some  of  the  cases  described 
by  the  older  writers  as  pyrosis  or  heartburn  under  what  we  now 
recognize  as  acid  hypersecretion. 

I  shall  revert  to  this  topic  while  considering  the  conditions  of 

*  F.  Damaschino.     Maladies  des  voies  digestives.     Paris.  1880. 
f  Germain  See.     Du  regime  alimentaire.     Paris,  1887  ;  Des  dyspepsias  gastroin- 
testinales.     Paris,  1883. 

X  Dujardin-Beaumetz.    L'Union  Medic,  July  23,  1892. 


194  DISEASES  OP  THE  STOMACH. 

hyperchlorhydria,  which  I  classify  among  the  neuroses  of  the  stom- 
ach. I  will  merely  say  here  that  of  necessity  we  must  differentiate 
between  a  catarrhal  (that  is,  a  chronic  inflammatory)  condition  of 
the  glandular  coat  of  the  stomach  and  the  nervous  affections  of  the 
same,  be  the  irritation  direct  or  indirect.  The  inflammatory  pro- 
cesses are  always  attended  by  a  lessening  of  the  glandular  secretion 
— i.  e.,  of  hydrochloric  acid  and  pepsin — and  instead  there  is  pro- 
duced a  more  or  less  alkaline  transudate.  The  sum  of  these  two 
factors  will  give  the  absolute  acidity  or  alkalinity  of  the  stomach 
contents  as  produced  by  the  irritation  of  the  ingesta.  But  the  de- 
gree of  acidity  is  always  lessened,  and  it  is  therefore  a  distinct  con- 
tradiction of  the  pathological  meaning  of  the  term  inflammation, 
and  especially  of  chronic  catarrhal  processes,  to  speak  of  an  "  acid 
catarrh,"  as  has  been  done  up  to  recent  times,  in  absolute  violation 
of  fundamental  medical  principles.  In  spite  of  the  statements  of 
certain  authors  (Jaworski,  Korczynski,*  Dujardin-Beaumetz,  Hay- 
em  f ),  I  can  not  force  myself  to  accept  the  view  that  we  shall  desig- 
nate as  "  catarrhs  "  conditions  iu  which  there  is  hypersecretion  accom- 
panying a  more  or  less  marked  irritation  of  the  mucous  membrane. 
When  we  find  hyperacidity,  or,  to  speak  more  exactly,  hyperchlor- 
hydria, and  also  the  evidences  of  inflammation  of  the  mucosa  (cel- 
lular proliferation,  cloudiness  of  the  epithelium,  etc.),  the  latter 
must  be  regarded  as  secondary  to  the  former.  The  hyperchlor- 
hydria is  usually  due  to  some  nervous  influences  which  cause  an 
overactivity  of  the  secretory  apparatus  ;  and  it  exists  in  spite  of  the 
damage  to  part  of  the  secretory  parenchyma  as  an  evidence  of  the 
overactivity  of  the  intact  portion,  but  not  as  the  result  of  a  "  so- 
called  acid  catarrh,"  as  Korczynski  and  Jaworski  have  proposed, 
since  the  adjective  "  so-called  "  shows  that  this  designation  is  purely 
arbitrary. 

It  is  entirely  different,  however,  with  the  coexisting  production 
of.  mucus,  which,  as  in  other  glands — the  submaxillary  gland,  for 
instance — does  not  go  hand  in  hand  with  the  formation  of  the  spe- 
cific secretion.     The  longer  the  stimulation  lasts  the  smaller  the 

*  Von  Korczynski  and  Jaworski.     Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  xlvii. 
f  Dujardin-Beaumetz.    Traitement  des  Maladies  de  restomac.     Paris,   1891, 
p.  337.— Hayem.    Gazette  hebdom.,  1893,  Nos.  33  and  34. 


PATHOLOGY   OP  CHRONIC  GASTRITIS.  195 

percentage  of  the  organic  constituents  of  the  saliva  will  be  than  the 
inorganic,  and  probably  (although  this  is  not  yet  absolutely  known) 
the  amount  of  mucus  and  ptyalin  will  stand  not  in  the  same  but  in 
the  reverse  proportion.*  Analogous  to  this,  the  secretion  of  mucus 
in  the  stomach  may  be  very  abundant,  and  yet  the  gastric  juice  may 
be  absolutely  wanting ;  such,  indeed,  is  often  the  case.  But  all 
those  conditions  which  are  accompanied  by  an  increased  secretion 
of  gastric  juice  must  be  classified  among  the  neuroses  of  the  stomach, 
whether  it  is  only  an  abnormal  reaction  to  a  normal  physiological 
stimulation — i.  e.,  occurring  only  during  digestion — or  whether  a 
continual  irritation  keeps  up  a  constant  secretion  of  the  glands. 
These  are  the  conditions  which  we  now  call  hyperchlorhydria  and 
hypersecretion.  In  accordance  with  these  views,  I  shall  describe 
these  conditions  among  the  nervous  disturbances  of  the  stomach. 
[This  view  is  not  shared  by  Boas,  Rosenheim,  and  others,  who  main- 
tain that  there  are  cases  of  chronic  gastritis  with  increased  acidity 
of  the  stomach  contents.  This  group  of  cases  is  called  gastritis 
acida.) 

Pathology. — The  anatomical  features  are  allied  to  the  conditions 
described  under  acute  gastritis.  For  the  greater  part  the  mucous 
membrane  has  a  yellowish-gray  or  slate-gray  color,  with  insular,  vas- 
cular, deeply  injected  areas  of  a  scarlet  or  brownish-red  color  ;  it  is 
usually  thickened,  on  an  average,  one  or  two  millimetres  [J-^  to  -^^ 
of  an  inch],  and  covered  with  a  delicate  but  firmly  adherent  layer 
of  mucus  ;  in  many  places  it  is  elevated  above  the  tense  submucosa, 
because  at  these  places  it  has  grown  more  rapidly  than  the  latter, 
and  forms  papillary  projections,  giving  rise  to  the  so-called  Stat 
mam£lonee,  a  term  which  at  all  events  is  applied  by  some  authors 
not  to  this  condition  but  to  the  polypoid  degeneration  of  the  mucous 
membrane.f  The  portion  of  the  stomach  usually  involved  is  the 
pylorus,  but  it  may  extend  to  the  fundus  and  even  the  entire  mu- 
cous membrane.  The  submucosa  and  muscularis  may  also  be  thick- 
ened, and  the  latter  especially  at  the  pylorus  may  cause  hypertrophy 
with  consecutive  stenosis.  To  this  condition  of  well-marked  hyper- 
trophy Brinton  has  applied  the  name  of  cirrhosis  of  the  stomach, 

*  Vide  Ewald.     Klinik,  etc.,  I.  Theil,  3te.    Auflage,  S.  47  and  50  et  seq. 
f  Orth.    Loc.  cit.,  p.  709. 


196  DISEASES  OP  THE  STOMACH. 

while  the  French  writers  *  call  it  hypertrophic  sclerosis  of  the  sub- 
miicosa  and  muscularis. 

The  minute  anatomy  of  the  process  is  that  of  a  parenchymatous 
and  interstitial  inflammation,  f  The  glandular  cells  are  partly  de- 
stroyed, partly  granular,  and  partly  shriveled  up  ;  differentiation 
between  the  principal  {Hauptsellen)  and  the  parietal  cells  {Belegzel- 


FiG.  27. — Mrs.  St.,  September  27, 1887.  From  a  pale,  reddish  shred,  the  size  of  a  grain  of 
sand,  which  was  found  between  some  pieces  of  mucus  in  the  wash-water  after  lavage 
of  the  empty  stomach.  J 

len)  is  impossible  ;  in  many  places,  especially  in  the  pyloric  region, 
the  ducts  have  lost  their  regular  order  of  lying  alongside  of  one 
another,  and  show  an   atypical   manifold  ramification  like  glove- 

*  Hanot  et  Gombauldt.  Arch,  de  physiol.,  ix,  p.  412. — Dubujadoux.  Gazette 
hebdom.,  1883,  p.  198. — Kahlden.  Ueber  chronische  sclerosirende  Gastritis.  Cen- 
tralblatt  fiir  klin.  Med.,  1887,  No.  16, 

t  [See  also  Hayem.  Gastritis  Parenchymatosa.  Wiener  Allgem.  med.  Zeit., 
1894,  Nos.  2-17.  Hayem  has  published  the  best  histological  studies  of  the  gastric 
mucous  membrane. — Ed.] 

X  [Some  light  has  been  shed  upon  the  changes  in  the  gastric  mucous  membrane 
by  the  study  of  the  fragments  of  tissue  which  are  frequently  found  in  the  wash- 
water  during  lavage,  as  was  originally  proposed  by  Boas.  A  most  elaborate  study, 
with  illustrations  and  complete  bibliography,  has  been  published  by  Cohnheim 
(Boas's  Archiv,  1895,  Bd.  i,  p.  274).  Einhorn  has  also  studied  this  subject  in  his 
publication  on  erosions  of  the  stomach  (N.  Y.  Medical  Record,  June  23,  1894),  in 
which  he  has  endeavored  to  construct  a  new  clinical  group  for  this  symptom — a 
grouping  which  does  not  seem  justified  when  one  considers  in  how  many  different 
conditions  these  fragments  may  be  found.  This  has  been  shown  in  Cohnheim's 
paper  and  also  in  Einhorn's  original  paper,  and  one  which  has  just  appeared  (The 
State  of  the  Gastric  Mucosa  in  Secretory  Disorders  of  the  Stomach,  N.  Y.  Medical 
Record,  June  27,  1896).  How  far  we  are  justified  in  drawing  conclusions  as  to  the 
condition  of  the  other  parts  of  the  mucosa  must  remain  an  open  question.  This 
much  seems  to  be  established  at  present,  that  as  yet  we  are  unable  to  associate  any 
definite  pathological  changes  in  the  fragments  of  tissue  with  the  various  diseases 
of  the  stomach. — Ed.] 


PATHOLOGY  OF  CHRONIC   GASTRITIS.  197 

fingers.  Isolated  glands  become  separated  at  the  fundus  and  appear 
at  the  border  of  the  submucosa  as  cysts,  which  are  either  empty, 
with  a  smooth  lining  membrane,  or  are  filled  with  the  remains  of 
glistening  hyaline  cuboidal  epithelium.  There  is  an  abundant  small- 
celled  infiltration  which  is  especially  marked  near  the  surface  of  the 
mucous  membrane ;  the  cells  lie  between  the  glands  and  in  places 
push  their  ducts  far  apart.  In  the  hyperplastic  form  we  see  pro- 
cesses of  connective  tissue  which  proceed  upward  between  the 
glands  from  the  submucosa  hke  the  branches  of  a  tree.  The  free 
surface  of  the  glandular  layer  is  covered  with  a  film  of  mucus  in- 
closing many  leucocytes  and  nuclei.  The  superficial  layer  of  the 
epithelium  of  the  mucosa  is  loosened,  and  can  be  separated  in  ad- 
herent shreds  which  may  sometimes  be  found  in  the  wash-water 
after  lavage  of  the  stomach.  In  the  accompanying  drawing  (Fig. 
27)  one  can  readily  see  the  mouths  of  the  glandular  ducts  and  the 
surrounding  epithelium.  The  epithelial  cells  of  the  Yorraum  [the 
short,  tunnellike  entrance  to  the  cavity  of  a  peptic  gland]  is  for  the 
greater  part  filled  with  a  pale  mucous  mass  which  projects  sharply 
against  the  lumen  without  any  inclosing  membrane,  as  described  by 
Kupffer  *  in  the  normal  stomach.  I  have  been  able  to  study  this 
and  the  following  conditions  in  specimens  which  were  obtained 
immediately  after  death,  or  from  living  persons  after  resection  of 
the  pylorus.  In  the  condition  (to  be  described  presently)  of  mucous 
catarrh  this  mucoid  degeneration  may  be  observed  to  extend  down 
to  the  base  of  the  glands,  so  that  in  place  of  the  ordinary  principal 
and  parietal  cells  we  only  find  cells  in  the  most  varied  stages  of 
mucoid  degeneration.  This  condition  is  especially  marked  in  the 
pyloric  region.  Isolated  cells  may  be  found  which  are  still  intact, 
the  mucus  filling  only  a  small  part  of  them,  while  the  rest  of  the 
cell  is  occupied  by  granular  protoplasm  and  a  large  nucleus.  In 
others  the  mucus  occupies  the  greater  part  of  the  cells  and  crowds 
the  protoplasm  and  the  fiattened  nucleus  against  its  base.  In  still 
others  the  cell  membrane  has  ruptured  and  the  mucus  has  escaped 
into  the  lumen  of  the  duct  of  the  gland,  where  it  has  been  precipi- 
tated in  streaks  by  the  alcohol.     This  gives  rise  to  very  delicate 

*  KupfEer.    Epithel  und  Driisen  des  menschlichen  Magens.     Miinchen,  1883. 
Tafel  I. 


198 


DISEASES  OP  THE  STOMACH. 


figures,  whicli  resemble  a  row  of  horseshoes  with  their  openings 
toward  the  lumen  of  the  gland.  Fig.  28  has  been  taken  from  a 
piece  of  mucous  membrane  which  was  placed  in  hardening  fluid  im- 


FiG.  28. — The  specimen  from  which  this  figure  has  been  drawn  is  from  a  piece  of  mucous 
membrane  which  was  placed  in  alcohol  immediately  after  its  removal  from  the  stomach, 
at  an  operation  for  resection  of  a  pyloric  carcinoma.  It  was  stained  by  Heidenhain's 
method  of  hsematoxylin  and  bichromate  of  potash.  On  the  right  side  of  the  figure  is  the 
upper  border  of  the  mucous  membrane,  showing  the  epithelium,  a  few  cells  of  which 
contain  mucin.  Directly  under  the  epithelium  is  a  small-celled  infiltration  which  ex- 
tends aci'oss  the  entire  mucous  membrane,  dipping  down  to  the  submucosa  between  the 
glandular  tubules,  separating  the  latter  and  obliterating  their  excretory  ducts.  The 
section,  being  oblique,  shows  one  portion  of  the  glands  in  longitudinal,  the  other  in 
transverse,  section.  In  the  glandular  cells  the  mucoid  degeneration  maj'  be  seen  to 
extend  in  even  as  far  as  their  fundal  portion.     (Camera  lucida.) 

mediately  after  excision.  Some  of  the  glands  ■  are  well  preserved, 
while  others  are  irregularly  formed,  but  only  in  the  pyloric  region, 
the  cells  of  which  are  in  various  stages  of  mucoid  degeneration. 


PATHOLOGY  OF  ATROPHY  OP  GASTRIC  MUCOSA.  I99 

Some  of  the  cells  are  still  intact ;  others  are  filled  with  granular 
protoplasm  and  a  large  nucleus  ;  in  still  others  the  greater  portion 
of  the  cell  consists  of  mucus  which  has  crowded  the  protoplasm  and 
nucleus  to  one  side  ;  finally,  there  are  others  in  which  the  cell  mem- 
brane has  burst,  the  mucus  has  been  poured  out  into  the  lumen  of 
the  gland,  and  has  been  precipitated  in  streaks  by  the  alcohol.  That 
this  is  really  mucus,  and  not  the  isolated  formation  of  vacuoles,  as 
described  by  Stohr  and  Sachs,  is  easily  proved  by  the  reaction  with 
acetic  acid  and  the  bluish  color  with  heematoxylin ;  yet,  I  repeat, 
these  features  are  only  found  where  the  mucous  membrane  has  been 
placed  in  alcohol  while  still  warm ;  in  older  tissues  I  have  never  met 
them.  Thus  there  is  a  mucoid  degeneration  of  the  protoplasm,  of 
the  cells,  which  extends  deep  down  into  the  fundus  of  the  gland. 
Whether  these  changes  may  retrograde,  or  whether  they  are  perma- 
nent, I  can  not  yet  decide  from  the  specimens  which  I  have  at 
present. 

As  the  disease  advances,  chronic  gastritis  finally  causes  retro- 
gressive changes  in  nutrition,  which  are  at  first  manifested  in  a  pro- 
gressive fatty  degeneration  of  the  glandular  cells,  and  which  finally 
cause  complete  atrophy  of  the  mucous  membrane,  a  condition  to 
which  Lewy  *  has  called  especial  attention.  This  led  to  further  in- 
vestigation on  this  subject,  although  it  had  already  been  carefully 
studied  and  illustrated  by  Fenwick ;  f  yet  these  pictures  are  very 
incomplete  according  to  our  present  notions.  Freund  X  has  also  de- 
scribed this  condition  in  a  monograph,  rich  in  historical  data,  under 
the  name  of  granular  degeneration  of  the  mucous  membrane  of  the 
stomach.  These  changes,  if  a  large  area,  or  especially  the  entire 
surface,  of  the  mucous  membrane  be  involved,  must  finally  lead  to 
a  total  destruction  of  the  secreting  parenchyma  with  all  its  conse- 
quences. 

[The  correctness  of  these  views  on  atrophy  of  the  gastric  mu- 


*  B,  Lewy.  Chronisehe  Gastritis  mit  Atrophic  der  Mucosa.  Ziegler's  Beitrage, 
Heft  1,  1886,— Ewald.  Ein  Fall  von  Atrophie  der  Magenschleimhaut.  Berl.  klin. 
Wochenschr.,  1886. 

f  L.  Fenwick.     On  Atrophy  of  the  Stomach.    London,  1880. 

X  W.  A.  Freund.     Ueber  den  etat  mamelonne  und  die  Granularentartung  der 
Magenschleimhaut.     Breslau,  1863. 
14 


200  DISEASES  OF  THE  STOMACH. 

cosa  have  been  questioned  by  Colinheim,*  who  quotes  Hammer- 
schlasi;  f  and  Schmidt  :j:  in  support  of  his  views.  Cohnheim  main- 
tains that  in  most  cases  it  is  only  the  true  secreting  portion  of  the 
mucosa  which  is  destroyed,  but  that  the  excretory  duct,  i.  e.,  the 
f oveal  layer — remains  intact,  or  is  even  hypertrophied.  The  rapid 
post-mortem  changes  usually  lead  to  the  destruction  of  these  super- 
ficial layers,  and  hence  it  is  only  by  the  examination  of  the  bits  of 
tissue  in  the  wash-water  during  lavage  that  the  real  condition  of  the 
mucosa  can  be  determined.] 

The  process  may  advance  in  two  different  ways :  *  1.  In  the  one 
form,  in  addition  to  the  above-described  degeneration  of  the  gland- 
ular cells,  and  a  small-celled  infiltration  of  the  interglandular  con- 
nective tissue,  there  is  a  progressive  destruction  of  the  glandular 
parenchyma,  so  that  finally,  as  may  be  seen  in  Fig.  29,  nothing  is 
left  but  a  layer  (whose  thickness  is  much  less  than  that  of  the  nor- 
mal mucosa)  of  small  round  cells,  between  which  isolated  remnants 
of  the  former  parenchyma  may  here  and  there  be  found. 

Toward  the  cavity  of  the  stomach,  what  was  formerly  the  gland- 
ular layer  is  limited  by  numerous  villi  infiltrated  with  many  round 
cells.  Toward  the  submucosa — i.  e.,  in  the  deeper  layers  of  the  mu- 
cous membrane — may  be  found  remnants  of  glandular  ducts  running 
obliquely ;  these  are  still  in  the  earlier  stages  of  the  process,  and 
some  of  them  have  been  converted  into  larger  or  smaller  cysts.  The 
latter  fact  proves  that  the  process  has  progressed  from  above  down- 
ward, and  has  first  obliterated  the  orifices  of  the  ducts.  Later,  even 
these  remnants  of  the  glands  disappear.  The  muscularis  mucosae  is 
much  thickened ;  the  submucosa  becomes  wider,  and  is  drawn  out 
into  a  network,  while  its  vessels  are  widely  dilated  without  showing 
any  marked  changes  in  their  walls.  A  peculiar  widening  of  the 
space  between  the  muscle  bundles  is  very  noticeable  in  the  muscu- 


*  [Cohnheim.     Loc.  ciL,  pp.  290-294.— Ed.J 

f  [Hammerschlag.     Wiener  klin.  Rundschau,  1895,  N"o.  23. — Ed.] 
X  [Schmidt.     Deutsch.  med.  Wochenschr.,  1895,  No.  19.— Ed.] 

*  The  description  of  these  conditions,  based  upon  specimens  which  I  prepared 
with  Dr.  George  Meyer,  was  first  given  by  me  at  the  meeting  of  the  Berliner  med. 
Gesellschaft  on  November  14,  1888.— Berl,  klin.  Wochenschr.,  1888,  No.  49.— [See 
also  G.  Meyer.  Zur  Kenntniss  der  sogenannten  "  Magenatrophie."  Zeitschr.  fur 
klin.  Med.,  Bd.  svi,  S.  366.— Ed.] 


PATHOLOGY  OF  ATROPHY  OF  GASTRIC   MUCOSA. 


201 


laris.  The  organ  in  toto  is  enlarged ;  its  walls  appear  thinned  and 
brightly  transparent  in  areas  or  throughout  its  entire  extent.  The 
whole  process  seems  to  be  a  parenchymatous  one  which  has  ex- 
tended from  the  surface  downward. 


Fig.  29.— From  a  case  of  anadenia  of  the  mucosa,  with  accompanying  dilatation  of  the  stom- 
ach. Instead  of  the  muco-^a  we  find  only  round  cells,  relatively  few  in  number,  which 
still  barely  indicate  the  normal  villuslike  arrangement.  The  muscularis  mucosse  is 
much  broader ;  the  submucosa  is  stretched  out,  and  contains  markedly  dilated  blood- 
vessels filled  with  blood-corpuscles.  The  muscularis,  which  is  not  represented  in  the 
drawing,  presented  a  peculiar  formation  of  spaces  between  the  individual  bundles  of 
muscle-fibers,  causing  it  to  look  like  a  network  of  cavities.    (Camera  lucida.) 

2.  The  other  form  is  characterized  by  a  marked  activity  of  the 
interstitial  connective  tissue,  and  leads  to  its  hypertrophic  prolifera- 


202 


DISEASES  OP  THE  STOMACH. 


tion,  which  proceeds  from  the  base  of  the  glands  upward  toward  the 
lumen  (Fig.  30). 

The  few  fibers  which  are  normally  found  above  the  muscularis 
mucosae  are  thickened ;  ascending'  and  branching  like  a  tree  between 
the  glands,  they  surround  them  and  cut  them  off.  Yet,  unlike  the 
first  form,  no  cysts  are  formed,  since  the  parenchymatous  cells,  hav- 
ing been  deprived  of  their  nutrition,  undergo  atrophy ;  so  that  finally, 


Fig.  30.— From  a  case  of  phthisis  ventriculi,  with  cirrhotic  atrophy.  Broad  bands  of  con- 
nective tissue  ascend  from  the  submucosa  (situated  to  the  right  in  the  ligure)  upward 
between  the  glandular  tubules,  embrace  them  and  cut  them  off,  thereby  causing  the 
destruction  of  the  parenchyma.  In  many  places  are  to  be  seen  numerous  round  cells, 
which  surround  the  base  of  the  glands,  and  also  lie  in  the  meshes  of  the  connective 
tissue.  Toward  the  free  surface  of  the  mucous  membrane  is  a  small-celled  infiltration. 
The  muscularis  mucosis  is  gone.  The  submucosa  has  been  converted  into  a  dense 
fibrous  mass  of  connective  tissue,  in  which  a  few  isolated  remnants  of  ruptured  glands 
may  be  found.     (Camera  lucida.) 

as  is  shown  in  Fig.  30,  there  remains  only  a  meshwork  with  large 
interstices  whose  fibers  run  parallel  to  and  terminate  smoothly  at 
the  surface.  Isolated  remnants  of  ducts  and  cells  may  be  found 
here  and  there  in  the  form  of  hyaline  inclosures.  The  muscularis 
mucosae  disappears  entirely,  the  submucosa  is  traversed  by  bands  of 
connective-tissue  fibers,  but  the  muscularis  is  apparently  unaltered. 


PATHOLOGY  OF  ATROPHY  OF  GASTRIC   MUCOSA.  203 

The  organ  is  usually  not  enlarged  in  toto,  but  at  times,  as  in  a 
case  reported  by  ITotlinagel,*  may  be  small  and  cirrhotic.  I  have 
examined  such  a  stomach,  the  capacity  of  which  was  only  180  c.  c. 
[f  ^  vj].  The  membrane  which  has  taken  the  place  of  the  mucous 
membrane  is  macroscopically  smooth  and  white,  gray,  or  slate-col- 
ored. In  such  cases  the  sclerotic  atrophy  involves  the  pyloric  region 
especially,  while  the  thinning  of  the  walls  of  the  stomach  occurs  in 
irregular  areas,  especially  at  the  fundus,  or  it  may  involve  the  entire 
organ. 

To  what  extent  the  walls  of  the  stomach  may  be  altered  by  this 
process  may  readily  be  perceived  from  the  following  measurements 
of  the  various  layers  made  by  Westphalen  : 


Normal  stomach. 

Atrophic  fimdus. 

Millimetre. + 
0-60 
0-05 
0-30 
0-70 

Millimetre. 
0-05 

Muscularis  mucos£e 

0-01 

0-gO 

Musculai'is 

0-13 

On  the  other  hand,  there  may  be  a  compensating  hypertrophy  of 
the  muscularis,  so  that  the  latter  may  be  twice  as  broad  as  usual. 
This  increase,  as  shown  by  a  case  which  I  have  examined,  is  due  to 
a  typical  hypertrophy  of  the  muscular  tissues. 

In  either  form  it  is  a  severe,  irreparable  process  which  specially 
involves  the  glandular  layer  of  the  stomach,  and  which  is  character- 
ized by  a  complete  disappearance  of  the  secreting  parenchyma.  I 
therefore  fully  agree  with  Dr.  George  Meyer,  who  wishes  to  abolish 
the  name  of  atrophy  of  the  stomach,  which  conveys  a  false  idea  of 
this  process,  and  proposes  as  a  substitute  phthisis  ventriouli,  gas- 
trie  phthisis  {Magenphthise).  As  an  amendment  I  would  propose 
the  name  Anadenie  des  Magens,  because  the  lesion  causes  a  total 
destruction  of  the  secreting  parenchyma.  It  is  hardly  necessary  to 
explain  that  such  terms  as  cata/rrhus  atrophicans  or  atrophicus  are 
ridiculous. 

*  Nothnagel.  Cirrhotische  Verkleinerung  des  Magens  und  Schwund  der  Lab- 
driisen  imter  dera  klinisehen  Bild  der  perniciSsen  Anamie.  Deutsch.  Archiv  fiir 
klin.  Med.,  Bd.  xxiv,  S.  58. 

f  [One  millimetre  equals  -^^  inch,— Ed.] 


204  DISEASES  OP  THE  STOMACH. 

Additional  cases  of  anadenia  have  since  been  reported,  of  wliich 
I  shall  only  mention  those  of  Westphalen,*  Klinkert,f  and  Hayem,:]: 
the  latter  of  whom  has  described  no  less  than  15  cases.  In  general, 
the  statements  which  I  have  just  made  above  are  confirmed,  and  no 
new  facts  are  presented,  with  the  exception  of  a  few  variations  in 


Fig.  31. — Total  atrophic  sclerosis  of  the  mucous  membrane,  which  has  been  converted  into 
a  long,  stretched-out  portion  of  connective  tissue,  with  isolated  round  cells,  and  hyaline 
remnants  of  former  glandular  tissues.  Toward  the  free  border  of  what  was  formerly 
the  mucous  membrane  (to  the  left  of  the  figure)  the  closer  packing  of  the  fibrous  bands 
has  formed  a  kind  of  limiting  membrane.  The  muscularis  mucosas  has  disappeared,  the 
submucosa  is  thinned,  and  consists  of  undulating  bands  of  connective  tissue.  Cysts 
may  be  seen  very  close  to  the  free  border  of  the  membrane. 

the  relation  of  the  interstitial  to  the  parenchymatous  inflammation 
and  the  proHferation  of  the  interstitial  tissue.  My  own  histological 
studies  do  not  enable  me  to  decide  whether  in  the  first  form  we  are 
only  dealing  with  secondary  processes  after  prolonged  catarrhal  in- 
flammation, or  whether,  as  claimed  by  some  writers,  like  Fenwick 
and  Eisenlohr,*  there  is  a  genuine  primary  atrophy  of  the  gastric 
mucosa.     I  believe  this  question  can  hardly  be  decided  from  the 

*  Westphalen.  Ein  Fall  hochgradiger  relativ  motorischer  Insuffieienz  des 
Magens  und  Atrophie  der  Magenschleimhaut.  St.  Petersburg,  med.  Wochensehr., 
1890,  No.  37. 

t  Klinkert.  De  klinisehe  beteekniss  van  der  atroph.  Maag-Katarrh.  Nederl. 
Weekbl.  v,  Geneesk.,  1892,  No.  5. 

X  Hayem.  Resume  de  I'anatomie  pathologique  de  la  gastrite  chronique.  Gaz. 
hebdora.,  1892,  Nos.  33  and  34. 

*  Eisenlohr.  Ueber  primare  Atrophie  der  Magen  und  Darmschleirahaut. 
Deutsch.  med.  Wochensehr.,  1892,  No.  49. 


POLYPI  OP  STOMACH.  205 

histological  appearances.  It  would  be  muchi  easier  to  assume  clin- 
ically that  a  primary  atrophy  might  occur  in  young  individuals  with- 
out an  antecedent  protracted  catarrh  in  the  sense  of  the  latter 
writers ;  yet  of  this  also  there  exist  no  unequivocal  proofs.  [Under 
the  name  achylia  gastrica,  Einhorn  *  includes  all  cases  in  which  the 
stomach  contents  contain  no  HCl  or  ferments ;  in  one  group  there 
is  atrophy  of  the  gastric  mucosa ;  in  the  other  the  mucous  mem- 
brane may  be  intact,  the  cause  of  the  absence  of  secretion  being 
nervous.]  At  all  events,  there  are  many  intermediate  stages  between 
the  simple  and  mucous  catarrhs  and  atrophy,  so  that  at  times  it  may 
be  impossible  to  difEerentiate  the  two  processes. 

So  much  for  these  final  stages  of  chronic  gastroadenitis. 

Another  change  arises  from  the  villous  outgrowths  from  be- 
tween the  small  depressions  in  the  gastric  mucous  membrane  ;  this 
gives  rise  to  the  polypoid  outgrowths  [polypi]  from  it,  usually  the 
size  of  a  milium  {Hirsekorn)  to  a  pea,  and  arranged  alongside  of  one 
another  in  large  numbers,  although  at  times  they  may  assume  larger 
dimensions.  Cruveilhier  has  a  drawing  of  a  specimen  in  which  the 
polypi  hang  down  from  the  mucous  membrane  like  the  teats  of  a 
young  bitch.  Ebstein  f  has  studied  their  structure  very  carefully, 
and  divides  them  into  the  pedunculated  and  the  non-pedunculated  ; 
those  occurring  in  groups  and  those  which  are  isolated ;  those  with  a 
smooth  and  those  with  a  polypoid  mucous  covering.  In  the  affected 
areas  the  connective  tissue  between  the  glands  is  always  increased 
and  forces  them  asunder.  The  mucous  membrane  and  submucosa 
are  thickened  in  larger  areas.  In  a  case  of  Lemaitre,:}:  carcinoma 
and  polypus  were  observed  together ;  amyloid  degeneration  of  the 
vessels  was  also  present.* 

It  is  well  known  that  intestinal  polypi  may  not  infrequently  give 
rise  to  a  partial  or  complete  intussusception  of  the  intestine,  yet  a 
similar  condition  due  to  gastric  polypi  is  a  very  rare  occurrence. 


*  [Einhorn.     Achylia  Gastrica.     N.  Y.  Medical  Record,  July  6,  1895.— Ed.] 

t  W.  Ebstein.     Die  polypose  Gesehwiilste  des  Magens.     Keichert  und  Du  Bois, 
Archiv,  1864.  S.  94. 

X  Camns-Corignon.     Des  polypes  de  I'estomac.    These  de  Paris,  1883. 

*  [An  excellent  picture  of  polyposis  of  the  stomach  may  be  found  in  Martin's 
Diseases  of  the  Stomach,  1895,  Fig.  23,  p.  240.— Ed.] 


206  DISEASES  OP  THE  STOMACH. 

Sucb.  a  case  of  mtussusception  of  the  stomach,  described  by  Chiari,* 
therefore  deserves  especial  mention. 

The  patient  was  a  woman,  forty-four  years  old,  who  had  died  of  ma- 
rasmus. During-  life  a  tumor  was  felt  at  the  pylorus  ;  there  was  emacia- 
tion, accompanied  by  vomiting  of  blood  ;  the  diagnosis  was  carcinoma  of 
the  pylorus  with  consecutive  dilatation  of  the  stomach.  At  the  autopsy  a 
funnel-shaped  depression  was  found  on  the  outer  wall  of  the  stomach  8 
centimetres  [3  inches]  from  the  pylorus,  and  into  which  the  middle  finger 
could  be  passed  6  centimetres  [2'4  inches]  toward  the  pylorus.  A  portion 
of  the  greater  omentum  had  been  drawn  into  this  intussuscepted  part  of 
the  stomach,  but  it  was  easily  replaced.  On  opening  the  stomach  it  was 
found  that  the  intussusception  was  due  to  three  large  polypi  like  cauli- 
flowers, situated  at  the  apex  of  the  prolapsed  portion  of  the  wall  of  the 
stomach  ;  together  they  formed  a  tumor  about  the  size  of  an  egg,  which 
extended  from  the  stomach  through  the  pylorus  into  the  duodenum,  to 
a  distance  of  2  centimetres  [0'8  inch].  Although  this  did  not  cause  a  com- 
plete obstruction  of  the  pylorus,  since  the  index  finger  could  still  be  easily 
passed  through  it  into  the  duodenum  alongside  of  the  polypi,  yet  there 
must  have  been  a  serious  obstruction  to  the  passage  of  food  from  the 
stomach  into  the  intestines.  This  explained  what  was  found  during  life, 
and  justified  the  error  in  the  diagnosis. 

The  situation  of  polypi  close  to  the  pylorus  explains  why  they  can  be 
drawn  downward  by  the  strong  contractions  of  this  part  of  the  stomach, 
and  thus  cause  an  intussusception.  The  latter  is  exceedingly  rare,  as  stated 
above,  when  the  polypi  are  situated  elsewhere. 

Etiology. — The  causes  of  chronic  gastritis  are  of  a  very  manifold 
nature.  First,  it  may  result  from  the  acute  and  subacute  forms,  as 
oft-repeated  attacks  frequently  lead  to  it,  especially  since  the  causes 
of  all  these  forms  may  be  the  same.  Such  irritants  can  act  more 
readily  when  the  mucous  membrane  has  been  altered  by  changes  in 
the  circulation  or  in  the  condition  of  the  blood,  the  mucous  mem- 
brane being  thus  rendered  more  sensitive  than  it  normally  is. 
Changes  in  the  circulation  may  be  produced  by  all  processes  which 
lead  to  venous  congestion  of  the  stomach — that  is,  the  affections  of 
the  organs  of  the  portal  system,  especially  of  the  liver  and  spleen  ; 
also  diseases  of  the  heart,  and  tuberculosis. 

Among  the  conditions  which  probably  predispose  to  chronic 
gastritis  by  an  altered  condition  of  the  blood  are  chlorosis,  scrofula, 
anaemia  after  dysentery,  typhoid  fever,  acute  exanthemata,  preg- 

*  A.  Chiari.  Ueber  Intussusception  am  Magen.  Prager  med.  Wochenschrift, 
1888,  No.  23. 


ETIOLOGY  OF  CHRONIC   GASTRITIS.  207 

nancy,  and  uterine  diseases  ;  also  diabetes,  gout,  and  chronic  affec- 
tions of  the  kidney. 

Finally,  chronic  gastritis  may  also  result  from  direct  local  irrita- 
tion, either  as  a  consequence  of  cicatrices  and  neoplasms  in  the  mu- 
cous membrane,  or  irritating  substances  which  are  brought  in  con- 
tact for  a  long  time  with  the  gastric  mucous  membrane,  either  from 
without  or  from  the  blood.  Among  the  former  is  the  swallowing 
of  large,  half -digested,  and  insufficiently  insalivated  morsels  of  food, 
which  irritate  the  gastric  mucosa,  either  directly  or  indirectly,  by 
predisposing  to  fermentation  of  the  stomach  contents.  Another 
source  of  irritation  from  without  may  be  putrefaction  in  the  mouth 
from  carious  teeth  or  inflammation  of  the  gums  ;  these  putrid  prod- 
ucts are  swallowed,  and  may  cause  inflammation  directly  or  indi- 
rectly. To  this  category  also  belongs  tobacco  juice,  which  fre- 
quently produces  first  a  subacute  and  then  a  chronic  inflammation  ; 
also  concentrated  alcoholic  beverages,  and  condiments  in  the  food 
which  may  cause  chronic  changes  after  prolonged  abuse ;  finally, 
true  toxic  substances  or  parasites  Hke  trichinse,  worms,  larvae,  etc. 
On  the  other  hand,  there  are  also  certain  toxic  substances  which 
circulate  in  the  blood  and  are  excreted  in  the  stomach — e.  g.,  urea 
in  chronic  renal  diseases,  and  the  products  of  intestinal  putrefaction 
in  constipation. 

[Turck  *  has  conclusively  shown  the  close  relation  that  exists  in 
many  cases  between  diseases  of  the  mouth  and  nasopharynx  and 
chronic  inflammation  of  the  stomach  and  intestines.  He  maintains 
that  "  the  invasion  of  the  stomach  from  the  infected  mouth  and  phar- 
ynx is  supported  by  the  fact  that  many  of  the  known  pathogenic 
micro-organisms  present  identical  biological  and  morphological 
forms  in  cases  of  gastritis  as  the  micro-organisms  found  in  diseases 
of  the  mouths  and  post-nasal  cavities  of  the  same  patients."  He 
also  urges  that  the  decomposition  of  the  food  and  the  growth  of 
micro-organisms  in  the  stomach  lead  to  the  formation  of  poisons 
which  may  be  absorbed  and  produce  both  general  toxic  effects  and 
local  irritation.] 

The  continual  regurgitation  of  bile  into  the  stomach  has  been 

*  [Turck.  N.  Y.  Medical  Journal  November  23,  1895,  p.  648 ;  ibid.,  February 
22,  1896 ;  Medical  News,  April  4,  189G,  p.  373.— Ed.] 


208  DISEASES  OF  THE  STOMACH. 

regarded  as  a  special  etiological  factor.  Althougli  the  investigations 
of  Dastre  and  Oddi  *  show  that  even  large  quantities  of  bile  may 
have  no  effect  on  digestion,  yet  the  results  of  these  experiments  of 
animals  are  directly  opposed  to  the  old  views  on  this  subject ;  and, 
according  to  the  observations  of  Yon  den  Yelden,  Malbrane,  Iliegel,t 
Weill,:]:  and  my  own  experience,  it  is  beyond  any  doubt  that  a  contin- 
ual regurgitation  of  bile  may  cause  chronic  disturbances  of  digestion. 
But,  as  shown  by  Boas,  in  such  cases  the  bile  merely  acts  as  an  ant- 
acid, since  the  biliary  albumen  and  mucus  combine  with  the  HCl, 
and  it  will  depend  entirely  upon  the  energy  of  the  HCl  secretion  and 
the  amount  of  regurgitated  bile  as  to  how  much  the  gastric  digestion 
will  be  disturbed,  and  to  what  degree  the  mucosa  will  be  irritated. 

The  most  important  of  these  etiological  factors  is  always  the 
entrance  of  the  above-mentioned  injurious  substances,  and  as  these 
are  usually  taken  of  the  sufferer's  own  free  will,  the  disease  may  be 
classified  among  those  in  which  the  patient's  indiscretions  play  a 
very  important  role.  But  as  most  persons  treat  their  stomachs 
badly,  and  are  neither  able  to  resist  culinary  temptations  nor  take 
sufficient  precautions  at  the  beginning  of  their  trouble,  chronic  gas- 
tric catarrh  is  one  of  the  "  best-nourished  "  and  most  prevalent  dis- 
eases in  the  world.    Indigestion  is  the  remorse  of  a  guilty  stomach  ! 

Clinical  History. — The  disease  presents  itself  in  two  clinical 
forms,  which,  when  fully  developed,  are  easily  differentiated : 
Chronic  simple  gastritis  {catarrhus  gastricus  chronicus)  and  chronic 
mucous  gastritis  [cata/rrhus  gastricus  mucosus)  [Hayem's  gastrite 
parenchymateuse  muquese]  ;  both  of  these  may  finally  lead  to 
atrophy  of  the  m,ucous  mem'brane.  Although  the  symptoms  of 
these  different  conditions  have  long  been  known  and  described,  yet 
on  the  one  hand  they  have  not  been  described  as  independent  dis- 
eases, nor  on  the  other  hand  has  their  mutual  connection  been  rec- 
ognized.   Boas,*  by  using  the  new  methods  of  examination,  deserves 

*  Dastre.     Recherches  sur  la  bile.    Archives  de  physiologie,  April,  1890,  p.  315. 
f  Riegel.    Beitrage  zur  Diagnostik  und  Therapie  der  Magenkrankheiten.    Zeit- 

schr.  fiir  klin.  Med.,  Bd.  xi,  p.  87. 

X  E.  Weill.    Du  refleux  permanent  de  la  bile  dans  Festomac.    Lyon  medicale, 
December,  1890. 

*  J.  Boas.      Zur  Symptomatologie  des  chronischen   Magenkatarrhs  und   der 
Atrophic  der  Magenschleimhaut.     Munch,  med.  Wochenschr.,  1887,  No.  43. 


SYMPTOMS  OF  CHRONIC  GASTRITIS.  209 

the  credit  of  having  differentiated  the  atrophic  from  the  mucous 
form. 

In  the  initial  stages  the  subjective  symptoms  are  about  the  same 
in  the  different  forms,  namely,  those  of  difficult  digestion,  or  of 
chronic  dyspepsia  ;  it  is  only  after  the  development  of  a  progressive 
phthisis  (atrophy)  of  the  gastric  mucous  membrane — and,  as  it  seems, 
only  after  it  has  been  established  for  a  long  time — that  the  symp- 
toms of  rapid  decline  of  the  organism  become  manifest.  The  differ- 
entiation really  depends  on  the  result  of  the  chemical  examination 
of  the  stomach  contents. 

I  shall  first  consider  the  local  and  general  symptoms  which  are 
common  to  all.  The  patients  usually  complain  of  a  dry,  pasty,  or 
salty  taste  in  the  mouth,  which  is  also  communicated  to  the  food 
during  mastication.  There  is  nothing  characteristic  about  the 
tongue  ;  it  is  seldom  clean,  but  usually  coated,  either  entirely  or  at 
the  base,  where  the  reddened,  swollen  papillae  project  like  straw- 
berries, while  the  edges  bear  the  impressions  of  the  teeth ;  the  thick 
fur  which  accompanies  carcinoma  [of  the  stomach]  is  usually  absent. 
The  tongues  of  delicate  ansemic  patients  have  a  more  uniform  trans- 
parent coating,  giving  the  organ  a  bluish- white  color.  Occasionally 
aphthae  form  at  the  edges  and  cause  the  patient  much  annoyance. 
In  the  morning  the  coat  is  much  thicker  than  in  the  evening,  be- 
cause the  movements  of  the  tongue  serve  to  keep  it  clean  ;  if  some 
teeth  are  missing,  we  notice  that  the  coating  is  thicker  on  that  side, 
although  this  is  not  always  to  be  explained  thus.  The  lips  are  usu- 
ally dry  and  chapped.  Belching  is  very  frequent ;  the  gas  is  either 
odorless  or  has  an  offensive  sour  smell  and  disagreeably  rancid  taste. 
It  is  frequently  accompanied  by  the  regurgitation  of  fluid  or  rem- 
nants of  food  from  the  stomach,  having  a  very  sour  and  disagree- 
able taste ;  these  regurgitated  masses  often  unpart  a  burning  and 
scratching  sensation  along  the  oesophagus — heartburn  or  pyrosis, 
the  ardor  ventriculi  of  Hoffman.  If  this  sensation  is  limited  to 
the  lower  section  of  the  oesophagus,  or  to  the  cardia,  and  is  of  an 
intense  character,  it  may  be  termed  cardialgia.  Such  an  exact  dis- 
tinction between  pyrosis  and  cardialgia  is  usually  impossible,  even 
if  Cullen,  of  Scotland,  has  described,  under  the  name  of  pyrosis,  a 
peculiar  group  of  symptoms  of  violent  cardialgia  occurring,  espe- 


210  DISEASES  OP  THE  STOMACH. 

cially  among  the  Scotch  country  people,  paroxysmallj  in  the  morn- 
ing before  eating,  and  which  is  relieved  by  the  vomiting  of  a  watery 
fluid.  On  the  other  hand,  a  difference  must  be  made  between  car- 
dialgia  and  gast^algia,  and  they  must  not  be  used  indiscriminately 
for  each  other,  as  is  done  by  the  older  writers.  The  latter  is  a 
diffuse  pain  in  the  stomach ;  the  former  is  a  pain  limited,  as  its 
name  denotes,  to  about  the  situation  of  the  cardia,  at  the  line  of 
junction  between  the  body  of  the  sternum  and  the  ensiform  process 
at  the  level  of  the  sternal  attachment  of  the  seventh  rib.  But  when 
the  heartburn  is  especially  pronounced,  whether  along  the  entire 
course  of  the  oesophagus  or  only  at  the  cardia,  or  whether  only  sour 
masses  are  regurgitated  into  the  mouth  without  causing  any  marked 
burning  sensation  in  the  oesophagus,  it  is  always  important  to  en- 
deavor to  ascertain  its  exact  nature,  and  to  distinguish  sharply 
between  the  sour  masses  whose  acidity  is  due  to  the  products  of 
fermentation  and  putrefaction  (acetic  acid,  fatty  acids,  lactic  acid) 
and  such  as  owe  their  taste  to  an  exaggeration  of  the  normal  acidity 
of  the  gastric  juice  (i.  e.,  to  a  hypersecretion  of  hydrochloric  acid), 
and  finally  from  those  somewhat  paradoxical  cases  in  which,  in  spite 
of  the  symptoms  of  pyrosis,  as  shown  by  MadSTaught,*  the  acidity 
and  condition  of  the  stomach  contents  are  normal.  It  is  only  the 
first  of  these  forms  (which  had  been  described  by  Graves  as  long 
ago  as  1823)  which  is  to  be  considered  as  belonging  to  chronic  gas- 
tritis ;  the  other  two  forms  are  to  be  classed  with  the  neuroses  of 
the  stomach.  In  the  latter  conditions  there  may  sometimes  be  such 
an  intolerance  toward  acids  that,  as  Talma  f  has  observed,  the  ad- 
ministration of  solutions  of  hydrochloric  acid  of  normal  or  even 
subnormal  acidity  may  produce  the  symptoms  of  pyrosis  and  car- 
dialgia  in  nervous  persons. 

Yomiting  is  of  very  irregular  occurrence  ;  the  condition  of  the 
vomited  masses  depends  on  the  stage  of  the  disease,  so  that  the 
amount  of  digestive  and  putrefactive  products  contained  in  them 
varies  a  great  deal.  IS'ausea  and  even  trismus  usually  precede  it. 
The  appetite  is  either  slight  or  may  be  lacking  entirely ;  yet  the 

*  MacNaught.     Med.  Chronicle  [Manchester],  January,  1885. 
f  Talma.     Ueber  Behandlung  von  Magenkrankheiten.     Zeitschrift  fiir  klin. 
Med.,  Bd.  viii,  p.  407. 


ATONY   OF  STOMACH.  211 

good  and  bad  phases  alternate,  so  that  in  the  former  the  patients 
often  easily  commit  dietetic  errors  and  cause  fresh  irritation.  Many 
patients  go  to  the  table  with  good  appetites,  but  the  first  few  mor- 
sels satisfy  their  cravings ;  others  verify  the  saying,  ^'L'appetit  vient 
en  mangeanty  While  in  the  latter  there  is  just  enough  irritation 
to  stimulate  the  glands  to  secretion,  in  the  former  it  is  too  much  for 
the  irritable  mucous  membrane,  and  may  check  the  secretion  by 
causing  an  abnormal  hyperaemia.  Without  being  really  thirsty, 
most  patients  crave  some  sour  drink  or  fluids,  especially  while  eat- 
ing. Soon  after  a  meal  they  feel  oppressed  and  bloated ;  they 
do  not  complain  of  a  true  spontaneous  pain  in  the  epigastrium; 
it  is  more  of  a  choking,  a  vague  sensation  which  only  becomes  a 
slight  pain  on  pressure  over  the  stomach.  True  gastralgise  do  not 
belong  to  the  ordinary  symptoms,  and  their  occurrence  should  al- 
ways lead  us  to  suspect  the  presence  of  other  lesions.  The  patients 
very  frequently  have  the  feeling  that  the  food  remains  abnormally 
long  in  the  stomach,  and  they  often  describe  very  effectively  the 
vain  efforts  of  the  oppressed  viscus  to  drive  the  ingesta  on  into  the 
intestines. 

In  fact,  finally,  these  conditions  may  be  combined  with  weakness 
of  the  gastric  muscular  wall — atony  of  the  stomach — which  in  turn 
causes  a  lengthened  stay  of  the  food  in  the  stomach.  As  a  result, 
decomposition  takes  place  in  the  ingesta ;  the  carbohydrates  fer- 
ment ;  the  albumenoids  putrefy — a  condition  which  Escherich  has 
called  "alkaline  fermentation."  This  produces  distention  of  the 
stomach  with  gas,  eructation  of  offensive  gases,  and  regurgitation 
of  sour  and  rancid  masses.  The  distention  of  the  stomach  in  turn 
paralyzes  its  muscular  fibers  and  causes  a  feehng  of  tension  and 
pain ;  the  decomposed  or  insufficiently  digested  stomach  contents 
irritate  the  intestines,  and  the  conditions  thus  produced  are  reflected 
back  to  the  stomach,  and  thus  the  vicious  circle  which  is  present  in 
all  affections  of  the  stomach  is  completed.  I  shall  show  how  these 
conditions  may  finally  lead  to  dilatation  or  true  gastrectasis  (pp.  276 
et  seq.)  ;  here  I  wish  to  simply  add  that  these  decompositions  usually 
occur  toward  evening  ;  in  the  morning  they  may  be  absent  or  only 
very  slight. 

The  conception  and  the  term  atony  of  the  stomach  have  been 


212  DISEASES  OF   THE   STOMACH. 

used  so  long  in  the  pathology  of  the  stomach  that  the  attempts  of 
Yon  Pf ungen  *  to  describe  a  new  disease  under  this  title  do  not 
seem  to  me  to  be  justifiable.  If  by  the  term  atony  we  understand, 
as  its  name  denotes,  a  deficiency  in  the  muscular  tone,  and  as  a 
result  an  insufficient  muscular  activity,  a  mechanical  or  muscular 
insufficiency  of  the  stomach,  then  it  is  not  proper  for  certain  writers 
to  also  include  disturbances  of  the  glandular  secretion.  Atony  arises 
either  primarily  or  secondarily.  Primary  atony  is,  in  my  opinion, 
a  neurosis,  and  is  always  a  rarity.  Secondary  atony  is  associated 
with  nearly  all  affections  which  involve  larger  areas  of  the  gastric 
mucous  membrane  ;  in  fact,  we  may  say  that  the  first  marked  objec- 
tive symptoms  are  usually  due  to  the  atony,  since  before  the  tone  of 
the  organ  is  lost  the  damage  done  by  an  insufficient  secretion  or  in- 
complete absorption  is  compensated  by  the  muscular  fibers  of  the 
stomach — that  is,  the  chyme  is  still  properly  expelled  into  the  intes- 
tines. But  it  also  occurs  in  conditions  of  general  debility  which  lead 
to  torpor  and  insufficiency  of  individual  organs  as  well  as  of  the  gen- 
eral metabolism ;  hence  it  is  especially  frequently  observed  in  the 
initial  stages  of  rickets  and  scrofula  in  children,  and  also  in  phthisis, 
chlorosis,  etc.  The  large,  distended  abdomens  of  scrofulous  chil- 
dren are  classical  proofs  of  this.  Here  there  is  an  atony  of  the 
stomach  and  intestines  which  leads  to  manifold  disturbances  of 
digestion  and  nutrition,  and  causes  the  dilatation  of  the  stomach 
which  occurs  sooner  or  later,  as  I  have  already  stated.  In  these 
cases  the  atony  is  never  a  primary  lesion,  but  is  always  the  result 
of  a  general  dyscrasia.  It  is  only  primary  in  so  far  as  other  diseases 
of  the  stomach  arise  from  it.  Therefore,  atony  of  the  stomach  de- 
serves an  important  place,  as  was  first  shown  by  Eosenbach,f  and 
still  more  completely  applied  in  every  direction  by  Yon  Pfungen  in 
the  work  cited  above  ;  and  the  more  so  because  the  primary  forms 
with  their  mechanical  changes  influence  the  chemical  and  other 
functions  as  well  as  those  of  motion.  I  will  not  now  enter  into  an 
irrelevant  discussion  to  which  some  investigations  have  led  as  to 
whether  there  is  a  separate  disturbance  of  the  peristalsis  of  the  fun- 

*  R.  V.  Pfungen.     Ueber  Atonie  des  Magens.     Wien,  1887. 
f  Rosenbach.     Der  Meehanismus  und   die    Diagnose  der  Mageninsufficienz. 
Volkmann's  Klinische  Vortrage,  No.  153. 


CONSTIPATION  IN  CHRONIC  GASTRITIS.  213 

dal  or  pyloric  portions  of  tlie  stomacli ;  the  result  is  the  same,  so  far 
as  we  are  now  concerned,  but  I  will  consider  this  in  greater  detail 
when  speaking  of  atony  as  a  nervous  condition.  For  in  the  present 
cases  the  atony  is  only  a  secondary  pathological  process,  and  is  only 
to  be  regarded  as  a  symptom,  and  not  as  an  independent  disease. 
There  are  constitutional  reasons  why  it  appears  early  in  some  and 
later  in  others ;  why  the  course  is  mild  or  severe,  and  why  its  origin 
may  even  be  traced  back  to  childhood  in  some  cases  {mde  reports  of 
Wiederhofer,  Kundrat,  Comby,  and  others).  But  whether  the 
atony  is  primary  or  secondary,  it  leads  in  all  cases  to  a  relaxation 
and  distention  or  even  a  dilatation  of  the  viscus,  which,  as  Poensgen 
has  observed,  other  things  being  equal,  occurs  the  more  readily  the 
more  relaxed  the  anterior  abdominal  wall  is  and  the  less  support 
afforded  by  it  to  the  stomach.  [Boas  and  others  group  atony  of  the 
stomach  among  the  gastric  motor  disturbances  as  insufficiency  of 
the  stomach.  See  Chapter  VI,  on  Dilatation  of  the  Stomach.  Some 
authors,  such  as  Boas,*  assert  that  the  motor  functions  are  normal 
or  even  increased  in  chronic  gastritis,  and  that  rarely,  and  then 
only  in  long-standing  cases,  is  it  lessened.  He  claims  that  he  has 
never  seen  a  true  dilatation  follow  chronic  gastritis.  Be  this  as  it 
may,  it  is  very  important  to  consider  the  motility  of  the  stomach  in 
all  cases  of  chronic  gastritis,  especially  in  reference  to  treatment.] 

Constijyation  exists,  as  a  rule  /  exceptionally  the  evacuations  are 
regular ;  in  a  few  cases  diarrhoea  and  constipation  alternate  ;  if 
haemorrhoids  are  present,  as  frequently  happens,  the  movements 
are  painful.  The  stools  are  sometimes  light  colored,  sometimes 
dark  green,  or  they  may  be  very  offensive  and  contain  undigested 
food.  The  patients  have  the  sensation  that  the  evacuations  are  in- 
complete, and  suffer  much  from  flatulence  and  rumbling  in  the 
abdomen,  which  is  sometimes  loud  enough  to  be  heard  at  a  distance. 
Often,  instead  of  true  faeces,  the  stools  are  watery  or  slimy,  as  a  re- 
sult of  the  irritation  of  the  intestinal  mucous  membrane  by  hard 
scybalse  ;  for  if  the  rectum  of  these  patients  be  examined,  it  will 
be  found  full  of  hard  masses,  which  can  not  be  expelled  on  account 
of  the  paresis  of  the  muscular  fibers  of  the  gut. 

*  [Boas.    Magenkrankheiten.    Bd.  ii,  2te  Auflage,  p.  21. — Ed.] 


214:  DISEASES  OP   THE  STOMACH. 

The  urine  is  scanty,  deposits  urates  abundantly,  and  is  at  times 
alkaline  from  basic  salts.  Unfortunately,  as  yet  we  bave  no  exact 
investigations  to  sbow  bow  tbe  disturbances  of  tbe  metabolism  are 
manifested  tbrougb  tbe  kidneys,  altbougb  in  connection  witb  our 
recent  knowledge  of  tbe  formation  of  alkaloids  in  tbe  organism  tbis 
would  seem  to  be  a  very  promising  field  for  investigation. 

Emaciation  occurs  soon,  and  is  tbe  more  marked  and  earlier  in  its 
appearance  tbe  stouter  tbe  patients  bave  previously  been  ;  losses  of 
15  to  25  kilogrammes  [33  to  60  pounds]  may  often  occur  in  a  few 
weeks.  In  older  patients  tbis  may  occasion  tbe  gravest  suspicions 
as  to  tbe  nature  of  tbe  illness,  wbicb  may  only  be  cleared  up  by  tbe 
subsequent  course  of  tbe  disease. 

Among  tbe  general  symptoms  we  notice  a  diminution  of  mental 
activity,  disinclination  to  bodily  exertion,  languor  durmg  tbe  day, 
especially  after  meals,  beadacbe  or  a  feeling  of  oppression  in  tbe 
head,  and  a  morose,  irritable  disposition.  In  some  patients  tbe  head- 
aches are  only  relieved  after  vomiting  slimy,  bile-stained  masses ;  in 
others  they  are  accompanied  by  a  burning  sensation  in  the  stomach, 
or  "  stomach  cramps,"  which  may  occur  periodically  for  years ;  such 
attacks  may  even  date  back  to  early  youth.  In  one  of  my  patients 
there  was  a  distinct  hereditary  factor  (grandfather,  father,  brothers, 
and  sisters).  The  patients  frequently  complain  of  a  feeling  of  heavi- 
ness in  every  limb,  cold  extremities,  itching,  and  formication.  Sleep 
is  deep  and  longer  than  usual,  but  is  not  refreshing,  and  is  disturbed 
by  hideous  dreams.  Yawning  is  frequent,  and  is  accompanied  by 
an  unpleasant  sensation  of  puckering  in  the  mouth  and  an  increased 
flow  of  saliva.  The  patients  "hack"  very  frequently,  and  expec- 
torate tenacious  mucus  containing  dark  particles.  Tbis  is  the  so- 
called  "  stomach  cough  of  dyspeptics,"  which  of  course  has  no  more 
to  do  witb  tbe  stomach  than  that  tbe  pharyngeal  catarrh  which 
causes  it  is  usually  due  to  the  same  factors  as  the  gastritis — i.  e., 
abuse  of  irritating  substances,  especially  alcohohc  beverages.*  At 
all  events,  it  may  happen  that  the  already  inflamed  pharyngeal  mu- 

*  The  existence  of  a  true  "  stomach  cough  "  has  not  yet  been  proved — that  is,  a 
reflex  act  starting  from  the  mucous  membrane  of  the  stomach  and  causing  acts 
of  coughing.  Such  eminent  authors  as  Naunyn  [Deutsch.  Archiv  fur  klin.  Med., 
1879,  Bd.  xxiii],  Nothnagel,  and  EdlefEsen  [ibid.,  1877,  Bd.  xx]  directly  deny  it. 


DYSPEPTIC    ASTHMA.  215 

cous  membrane  may  be  irritated  by  the  regurgitation  of  the  acid 
stomach  contents,  and  thus  may  cause  cough  reflexes  to  be  sent  out 
from  the  crossing  of  the  oesophagus  and  bronchi.  Such  "  coughs  " 
usually  disappear  after  neutralizing  or  lessening  the  acidity  of  the 
stomach  contents. 

The  pulse  is  small  and  weak,  sometimes  intermittent,  and  this 
irregularity  of  the  heart  action  is  felt  by  the  patient  as  palpitation. 
Some  patients  have  a  certain  characteristic  odor  which  is  also  com- 
municated to  their  underwear,  and  with  each  exacerbation  this  odor 
becomes  stronger.  Evening  rises  of  temperature  may  also  be  ob- 
served in  this  disease,  and  have  indeed  required  antipyretic  treat- 
ment, and  have  even  been  mistaken  for  typhoid  fever  [or  malaria].* 

All  of  the  above  symptoms  will  not  be  found  in  all  cases  nor 
even  in  the  majority  of  them.  Sometimes  one,  sometimes  another 
symptom  will  predominate  and  characterize  the  clinical  picture. 
Thus  some  patients  complain  only  of  the  distention  of  the  abdo- 
men and  marked  dyspnoea,  and  we  have  the  group  of  symptoms 
described  as  dyspeptic  asthma  {asthma  dyspepticum).  Others  are 
annoyed  especially  by  the  cough,  loss  of  appetite,  acid  regurgitation, 
choking  and  burning  sensation  in  the  abdomen.  In  still  others,  the 
irregular  heart  action,  palpitation,  irregular  and  intermittent  pulse 
are  especially  prominent  and  may  arouse  suspicions  of  organic  car- 
diac disease.  These  symptoms  occur  especially  during  digestion, 
are  complicated  by  pulsation  in  the  epigastrium,  but  are  less  marked 
when  the  stomach  contents  pass  into  the  intestines  or  when  the  ten- 
sion is  lessened  by  belching  up  gas.  A  variety  of  this  cardiac  dys- 
pepsia, which  had  already  been  described  by  Henoch,t  has  been 
especially  studied  and  published  by  Eosenbach.;}:  (See  Chapter  X, 
on  the  Gastric  IsTeuroses.)     But  common  to  all  patients  is  the  very 


A  case  of  paroxysmal  coughing  proceeding  reflexly  from  the  gastric  mucosa  has 
been  published  by  E.  Bull,  Deutsch.  Archiv  fiir  klin.  Med.,  Bd.  xli,  S.  472.  [Brun- 
ton  (Disorders  of  Digestion,  p.  40)  believes  that  stomach-coughs  are  due  to  the 
association  of  mild  inflammatory  conditions  of  the  upper  passages  with  the  pres- 
ence of  some  irritant  in  the  stomach. — Ed.] 

*  [On  the  other  hand,  cases  not  infrequently  occur  in  which  the  dyspeptic  symp- 
toms, gastralgia,  and  vague  fever  disappear  promptly  on  the  administration  of  anti- 
periodic  remedies.— Ed.]  f  Loc.  cit,  p.  391. 

X  0.  Rosenbach.    Neurose  des  Vagus  bei  Dyspepsie.    Deutsch.  med.  Wochenschr., 
1879,  Nos.  42  and  43. 
15 


216  DISEASES  OP  THE   STOMACH. 

slight  tenderness  on  pressure  or  spontaneous  pain  in  tlie  epigastrium 
and  tlie  chemical  changes  in  the  digestive  processes. 

Here  I  may  also  mention  that  peculiar  condition  first  described 
by  Trousseau  as  vertigo  gyrosa  or  vertigo  e  stomacho  laeso  {vertigo 
stomachalis),  gastric  vertigo,  and  also*  discussed  at  about  the  same 
time  by  Briick,  of  Osnabriick,*  as  Schwindelangst  ("  vertigo-fear  "), 
aura  vertiginosa ;  this  subject  has  since  been  carefully  studied  by 
Bloudeau,  Memeyer,  Yon  Basch,  Westphal,  Cordes,  Eyselein,  and 
others.  But  Trousseau  deserves  the  credit  of  having  first  directed 
attention  to  the  relation  of  these  attacks  of  vertigo  with  chronic 
catarrhal  gastritis.  They  occur  without  loss  of  consciousness,  begin 
usually  some  time  after  eating,  although  sometimes  they  may  be 
checked  by  taking  food,  but  can  not  be  produced  either  by  rapid 
circular  movements  or  by  inclining  the  head  forward,  or  similar 
motions.  The  attacks  pass  away  after  remaining  quiet  and  regu- 
lating the  diet,  but  are  usually  followed  by  severe  headaches.  Some- 
times these  attacks  assrme  the  form  of  the  agoraphobia,  and  have 
been  described  as  such  by  the  writers  last  mentioned  above.  Here 
the  patients  experience  an  indefinable  terror ;  they  may  even  be 
unable  to  go  alone  over  large  open  fields,  places,  or  broad  streets, 
either  avoiding  crossing  such  places  entirely  or  seeking  company 
even  of  strangers.  Granting  that  these  conditions  actually  belong 
to  or  border  upon  the  mild  psychoses,  yet  they  must  not  be  re- 
garded as  neuroses  of  the  stomach  in  the  sense  that  there  is  a  dis- 
ease of  this  organ  due  directly  or  indirectly  to  the  nervous  system. 
On  the  other  hand,  they  must  be  considered  reflexes  from  an  organic 
disease  of  the  stomach  upon  the  brain,  and  are  thus  to  be  sharply 
differentiated  from  the  conditions  to  be  presently  described  as  nerv- 
ous dyspepsia.  We  may  accept  the  explanation  of  their  origin  pro- 
posed by  Mayer  and  Pribram,  that  the  arterial  pressure  in  the  cere- 
bral vessels  is  raised  by  the  reflexes  from  the  walls  of  the  stomach, 
or  the  assumption  of  Bernstein  and  Asp,  that  they  are  due  to  an  irri- 
tation of  the  splanchnic. 

The  following  cases  may  be  cited,  since  these  conditions  are  not 
common.    The  patients  were  middle-aged  men,  for  it  usually  occurs 

*  Briick.     "  Vom  Schwiiidel."    Hufeland's  Journal,  Bd.  xvii,  St.  5. 


ATROPHY  OP  THE   GASTRIC   MUCOSA.  217 

in  such  patients,  although  the  ages  of  the  54  cases  collected  bj 
Cordes  *  vary  between  nineteen  and  forty-seven  years.  Common  to 
all  of  them  is  the  chronic  catarrhal  gastritis,  and  the  disappearance 
of  the  agoraphobia  after  this  was  cured. 

The  first  case  was  a  captain,  who,  while  complaining  to  me  that  he  suf- 
fered from  mild  local  gastric  troubles  and  occasional  slight  headaches, 
said  that  for  some  time  he  had  also  experienced  real  terror  when  walking 
or  riding  over  large,  open  places  to  such  an  extent  that  he  was  unable  to 
cross  the  parade  ground  alone  ;  if  he  did  succeed  in  riding  over  it,  when 
halfway  across  he  was  seized  with  such  terror  that  he  had  to  dismount, 
and  that  then,  while  leading  his  horse  by  the  bridle,  he  could  proceed 
without  any  further  trouble. 

The  second  case  also  happened  to  be  a  military  officer,  on  duty  at  the 
ministry  of  war,  who  said  tliat  he  had  the  greatest  fear  of  a  smooth  level 
area  on  which  there  was  no  resting-place  for  the  eye.  Thus  he  could  not 
go  alone  through  large,  empty  rooms  with  hard-wood  fioors,  and  that  it 
was  especially  disagreeable  to  him  to  walk  on  the  smooth  asphalt  pave- 
ment, so  that  he  either  made  detoui>s  or  sought  company. 

The  third  case  was  a  government  employe  who  had  to  pass  over  an 
open  square  every  day  to  reach  his  office ;  at  first,  while  crossing  this,  a 
feeling  crept  over  him  that  it  was  impossible  to  reach  the  other  side,  and 
that  the  ground  shook  under  him.  If  he  attempted  to  force  his  way,  after 
a  few  steps  he  was  attacked  with  such  vertigo  that  he  feared  he  would 
fall,  and  had  to  give  up  the  attempt. 

In  all  these  cases  this  psychosis  disappeared  entirely  as  soon  as  the 
gastric  symptoms  were  cured  by  suitable  treatment. 

In  the  course  of  time  I  have  seen  a  number  of  such  cases  in 
which  it  has  usually  been  difficult  to  determine  whether  the  gastric 
disturbances  were  the  cause  or  a  sequel  of  a  general  neurosis. 
"  Theater-fear  "  {Theater angst)  seems  to  be  a  very  frequent  form 
of  agoraphobia  ;  it  attacks  the  patients  in  theaters,  concert  halls,  the 
circus,  meeting  places,  etc.  ;  they  can  only  sit  close  to  the  door  or 
keep  on  a  level  surface,  and  even  then  they  may  be  overcome  after 
a  little  while  so  that  they  must  rush  out  into  the  open  air.  Such 
attacks,  however,  often  depend  upon  the  stomach,  for  not  infre- 
quently they  may  be  checked  by  eating  a  piece  of  bread  or  chocolate 
or  by  taking  a  swallow  of  strong  wine  or  cognac.  [It  is  often  diffi- 
cult to  distinguish  these  cases  from  gastric  neurasthenia.] 

A  very  interesting  feature  is  the  final  stage  of  chronic  catarrhal 
gastritis  already  spoken  of  as  atrophy  of  the  mucous  membrane,  or 

*  Westphal's  Archiv,  Bd.  iii,  S.  521 ;  also  Bd.  v. 


218  DISEASES  OF  THE  STOMACH. 

better,  anadenia  \_dvd,  without ;  dS'^v,  gland]  of  the  stomach  (Ana- 
denie  des  Magens),  since  this  is  not  so  much  a  disturbance  of  nutri- 
tion which  spares  the  structure  of  the  tissue  ;  it  is  rather  a  process 
which  causes  a  complete  destruction  of  the  glandular  parenchyma, 
and  whose  gradual  development  has  been  designated  jpfdhisis  mu- 
coscB  by  G.  Meyer ;  it  has  also  been  improperly  called  gastric 
phthisis.  [These  cases  have  been  included  by  Einhorn  *  under 
achylia  gastrica.'] 

This  process  may  be  partial  or  complete  ;  it  assumes  importance 
only  in  the  latter  case,  since  the  destruction  of  circumscribed  areas 
in  the  former  may  easily  be  compensated  by  the  rest  of  the  paren- 
chyma. According  to  the  anatomical  details  of  the  lesion  already 
given,  we  observe  a  progressive  loss  of  secreting  elements  which 
must  finally  lead  to  a  total  abolition  of  secretion  ;  and  with  this  the 
digestive  activity  of  the  stomach  is  gradually  and  irrevocably  de- 
stroyed. The  consequences  of  this  process  are  self-evident.  After 
a  longer  or  shorter  period,  marked  by  dyspeptic  complaints,  so 
severe  a  disturbance  of  the  nutrition  is  developed  that  the  patient 
literally  pines  away  "  like  a  lamp  the  oil  of  which  has  not  been 
replenished,"  and  finally  dies  of  marasmus.  At  all  events,  we  now 
possess  sufficient  clinical  data  to  show  that  the  intestines  may  act 
vicariously  for  the  stomach,  and  may  assume  the  entire  task  of  as- 
similation of  the  nutrition. 

During  the  j)eriod  of  compensation  the  general  condition  of  the 
patient  will  depend  entirely  upon  the  extent  to  which  the  motor 
functions  of  the  stomach — i.  e.,  its  ability  to  forward  its  contents  on 
into  the  intestines — are  preserved  ;  in  other  words,  whether  the 
muscular  fibers  are  intact,  paretic  (dilatation),  or  have  increased 
power.  But  this  seems  to  be  limited  to  a  definite  time,  which  varies 
in  different  individuals  ;  for  sooner  or  later  pathological  processes 
also  attack  the  intestine  and  abolish  its  activity,  either  on  account 
of  the  extra  work  imposed  upon  it,  or  other  accidental  causes.  As 
the  observations  of  Jiirgens,  Blaschko,  Sasaki,  and  Eisenlohr  f  have 

*  Einhorn,  loc.  cit.,  and  Boas'  Arch.,  Bd.  i.  p.  158.  A  careful  study  of  this  con- 
dition, together  with  exhaustive  bibliography,  has  been  given  by  Stewart,  Amer. 
Journ.  Med.  Sciences,  1895,  vol.  ex,  p.  560.— Ed.] 

f  Eisenlohr.  Ueber  primare  Atrophic  der  Magen-  und  Darmschlcimhaut. 
Deutsch.  med.  Wochenschr.,  1893,  No.  49. 


ATROPHY  OF   THE   GASTRIC   MUCOSA.  219 

shown,  there  is  finally  also  an  atrophy  of  the  intestinal  walls  which 
manifests  itself  in  a  degeneration  of  the  muscular  layers,  the  nerv- 
ous apparatus,  and  atrophy  or  fatty  degeneration  of  the  mucosa. 
JSTow  are  added  the  symptoms  of  insufficient  regeneration  of  blood, 
a  picture  which  may  simulate  progressive  pernicious  anaemia,  unless 
there  has  been  such  a  gradual  failing  of  the  faculties  that  death  may 
be  said  to  have  resulted  "  from  old  age."  For  I  have  frequently 
convinced  myself  at  the  autopsy  table  that  in  many  of  the  cases  said 
to  have  died  from  old  age  there  has  actually  been  an  extensive  ana- 
denia,  usually  combined  with  dilatation  of  the  stomach.  "When  the 
compensatory  action  of  the  intestines  suddenly  ceases  a  fresh  dis- 
ease apparently  breaks  out.  I  have  repeatedly  seen  such  cases  after 
an  acute  febrile  disease,  such  as  influenza,  febrile  bronchial  catarrhs, 
etc. ;  they  are  suddenly  followed  by  a  group  of  symptoms  which  can 
only  be  regarded  as  the  result  of  anadenia.  A  number  of  these 
cases  progressively  became  worse  and  died  of  almost  complete  an- 
orexia ;  in  several  of  them  there  were  gastralgic  symptoms  and  per- 
versions of  taste  (e.  g.,  a  continual  fecal  taste).  The  diagnosis  was 
confirmed  at  the  autopsies. 

The  conditions  which  prevail  here  can  not  be  different  than  in 
other  viscera ;  at  least,  we  know  of  no  associated  organs  with  vege- 
tative functions  which  are  of  great  importance  to  the  economy 
where  one  could  replace  the  other  for  an  indefinite  time.  Of  course, 
we  know  that  it  can  be  done  for  a  short  period,  but  not  beyond 
that ;  it  is  true  of  the  lungs  as  well  as  of  the  kidneys.  The  same 
occurs  in  the  individual  sections  of  the  digestive  tract,  and  just  as  it 
is  impossible  to  nourish  a  person  indefinitely  per  rectum,  so  the 
stomach  can  not  permanently  lie  idle  ;  for  it  is  not  merely  a  place 
for  digestion  and  disinfection,  but  it  is  also  an  organ  of  vital  im- 
portance. 

The  association  of  these  atrophic  conditions  wdth  severe  anae- 
mias indirectly  brings  them  into  relation  with  certain  changes  in 
the  spinal  cord  which  have  been  discovered  by  Lichtheim.*  The 
latter  consist  of  scattered  miliary  foci,  or,  when  more  marked,  of 
extensive  degeneration  of  the  posterior  columns  and  other  parts  of 

*  Lichtheim.     Verhandl.  des  Congresses  fiir  innere  Med.,  1887.    [See  Fleiner. 
Boas'  Archiv,  Bd.  i,  p.  249.— Ed.] 


220  DISEASES  OP   THE   STOMACH. 

the  cord.  The  similarity  of  the  symptoms  to  those  of  pernicious 
ansemia  has  already*  been  noted  by  Fenwickjf  Bartels,:}:  Scheper- 
len,  *  and  Osier.  ||  Rosenheim  "^  has  observed  two  cases  which 
seemed  to  be  pernicious  anaemia.  Inasmuch  as  these  cases  also 
have  marked  changes  in  the  blood,  alterations  in  the  red  corpuscles, 
relative  increase  of  the  white,  and  the  formation  of  macrocytes  and 
microcytes,  the  question  may  arise  whether  pernicious  angemia  is 
really  an  independent  disease  or  is  the  result  of  anadenia  of  the 
stomach;  but  in  the  cases  of  pernicious  anaemia  described  by 
Quincke,  and  also  by  Immermann,  the  changes  found  in  the  stom- 
ach were  insignificant  as  compared  with  the  intensity  of  the  symp- 
toms. A  striking  feature  which  has  been  observed  by  several 
writers  (Fenwick,  Ewald,  and  l^othnagel)  is  the  good  condition  of 
the  subcutaneous  fat,  which,  however,  is  not  often  found  in  dis- 
ease of  the  blood,  in  consequence  of  the  lessened  thoroughness  of 
oxidation. 

I*^aturally,  this  variety  of  chronic  gastritis  is  especially  frequent 
in  older  persons,  since  the  compensatory  and  reconstituent  powers 
of  the  tissues  are  greater  in  the  young.  Most  of  the  cases  have 
been  over  forty  years  of  age,  and  in  the  two  young  patients,  eighteen 
and  twenty-one  years  old,  reported  by  Litten  ()  and  Einhorn,  the 
diagnosis  was  not  verified  by  autopsy. 

Under  favorable  conditions — i.  e.,  sufficient  compensation — the 
disease  may  last  many  years,  as  shown  in  a  case  described  by  Ein- 

*  [Austin  Flint  was  the  first  to  call  attention  to  the  relation  between  anaemia 
and  atrophy  of  the  gastric  glands.  He  expressed  the  opinion  that  some  cases  of 
obscure  and  profound  antemia  are  dependent  upon  degeneration  and  atrophy  of  the 
glands  of  the  stomach.  See  American  Medical  Times,  1860 ;  New  York  Medical 
Journal,  March.  1871 ;  Flint's  Practice  of  Medicine,  Philadelphia,  1881,  p.  477.— 
Quoted  by  Welch,  loc.  cit,  p.  616.— Ed.] 

f  S.  Fenwick.    Loc.  cit. 

X  Bartels.  Ein  Fall  von  pernicioser  Anamie  mit  Icterus.  Berliner  klin. 
Wochenschr.,  1888.  No.  3. 

*  Scheperlen.  Studier  angaaende  Anaemie.  Nord.  medic.  Arkiv,  1879,  Bd.  si. 
No.  3. 

II  Osier.  Atrophy  of  the  Stomach  with  the  Clinical  Features  of  Progressive 
Pernicious  Anaemia.     American  Journal  of  Med.  Sciences,  1886,  No.  4, 

^  T.  Rosenheim.     Loc.  cit. 

^  M.  Litten  und  Rosengart.  Ein  Fall  von  fast  volligen  Erlosehen  der  Secretion 
des  Magensaftes.  (Atrophie  der  Magenschleimhaut  der  Autoren.)  Zeitschrift  fur 
klin.  Med.,  Bd.  xiv,  S.  573. 


DIAGNOSIS  OF  CHRONIC   GASTRITIS.  221 

liorn.*  [A  number  of  cases  of  long  duration  and  occurring  in  per- 
sons under  fortj  years  have  since  been  reported.]  But  in  this  case, 
as  in  all  the  other  cases  which  were  first  described,  the  observers 
have  only  calculated  the  amount  of  free  HCl,  and  not  the  total 
HCl  as  well ;  thus  we  are  uncertain  whether  there  was  a  complete 
cessation  of  glandular  function  exerted  or  not.  [In  later  reports 
on  this  and  other  cases  Einhorn  states  that  combined  HCl  was  also 
always  absent.] 

Diagnosis. — The  objects  of  the  diagnosis  are,  first,  to  differen- 
tiate chronic  catarrhal  gastritis  and  its  results  from  other  diseases ; 
and,  secondly,  to  distinguish  its  varieties  from  one  another.  The 
disease  occurs  so  frequently  as  an  accompaniment  of  the  most 
varied  local  affections  of  the  stomach  that  I  will  disregard  its  sec- 
ondary occurrence  and  restrict  myself  to  the  genuine  varieties. 
From  the  description  of  the  symptoms  already  given  it  may  readily 
be  inferred  that  the  diagnosis  of  such  a  true  gastritis  can  only  be 
made  by  exclusion — that  is,  after  having  shut  out  all  the  other  or- 
ganic and  functional  disorders  of  the  organ.  An  idiopathic  gastri- 
tis can  only  be  diagnosticated  after  ulcer,  carcinoma,  dilatation, 
neuroses,  or  any  of  the  acute  disorders  already  described  has  been 
excluded.  What  is  left  is  gastritis ;  but  just  as  readily  as  the  diag- 
nosis "  chronic  gastric  catarrh  "  is  made,  just  so  little  is  such  an 
offhand  opinion  justified  in  many  cases,  for  the  symptoms  of 
chronic  gastritis  may  at  times  simulate  any  of  the  above-mentioned 
disorders,  and  neither  the  duration,  nor  the  etiology,  nor  the  kind 
of  dyspeptic  manifestations  will  suffice  to  make  the  diagnosis  at 
once,  but  in  addition  there  must  be  a  careful  examination  with  the 
aid  of  all  our  modern  diagnostic  resources.  The  diagnosis  of 
chronic  gastritis  having  been  made  in  this  way,  the  next  step  is  to 
determine  which  variety  we  have  before  us.  Our  only  means  for 
this  purpose  is  the  examination  of  the  stomach  contents.  The  re- 
sults of  these  may  be  grouped  as  follows  : 

1.  Siinple  chronic  gastritis.  While  fasting,  the  stomach  con- 
tains only  a  small  quantity  of  a  watery,  mucous  fluid,  frequently 

*  Einhorn.     Achylia  gastrica.    N.  Y.  Med.  Record,  June  11,  1893. 


222  DISEASES   OF   THE   STOMACH. 

tinged  yellow  or  yellowish-green  by  bile,  and  sometimes  mixed 
with  duodenal  contents.  On  standing,  it  deposits  a  sediment  con- 
taining epithelial  cells  of  various  sizes  and  shapes,  numerous  round 
cells  and  free  nuclei,  also  small  quantities  of  remnants  of  food, 
starch  granules,  muscle  fibrillse,  and  vegetable  cellular  tissue.  After 
the  test  breakfast  the  acidity  is  variable  but  never  increased ;  the 
quantity  of  hydrochloric  acid  is  lessened.  Pepsin  and  rennet  are 
small  in  amount,  but  form  propeptone  and  peptone  even  in  the 
stomach ;  can  digest  [in  artificial  digestion]  after  acidulating. 

2.  Chronic  mttcous  gastritis.  This  differs  from  the  simple 
form  by  the  abundance  of  mucus  in  the  contents  of  the  stomach 
while  fasting  and  after  taking  food,  so  that  acetic  acid  always  gives 
a  marked  mucin  reaction.  Acidity  always  low.  Hydrochloric  acid 
usually  absent.  Propeptone  very  abundant,  peptone  only  in  traces. 
Digestion  [in  the  test  tube]  occurs  only  after  adding  hydrochloric 
acid,  and  is  slow  even  then.  Curdling  by  rennet  is  tardy  or  absent. 
In  the  wash-water  after  lavage  small,  bloody  fragments  of  the  epi- 
thelial covering  of  the  mucous  membrane  may  occasionally  be  found. 

3.  Atrophy.  This  differs  from  the  two  varieties  already  named 
in  that  while  fasting  the  stomach  is  usually  empty,  and  that  the 
chyme  expressed  after  the  test  breakfast  contains  neither  mucus, 
hydrochloric  acid,  pepsin,  nor  rennet  ferment.  [The  stomach  con- 
tents obtained  after  the  test  breakfast  are  very  characteristic  in  ap- 
pearance. The  pieces  of  the  roll  are  unchanged  and  are  not  at  all 
digested ;  the  amount  of  fluid  is  small,  and  hence  it  is  often  quite 
difiicult  to  express  the  stomach  contents.  Pennet  zymogen  is  some- 
times found  when  all  other  kinds  of  ferment  are  absent.]  At  all 
events,  some  caution  is  required  in  determining  the  absence  of  pep- 
sin. Jaworski  properly  calls  attention  to  the  fact  that  the  simple 
addition  of  a  few  drops  of  hydrochloric  acid  to  gastric  contents  con- 
taining none  of  this  acid,  before  trying  artificial  digestion  in  the 
test  tube,  is  not  sufliicient  to  determine  the  presence  or  absence  of 
pepsin.  On  the  contrary,  enough  acid  must  be  added  till  the  color 
tests  indicate  the  presence  of  free  acid  ;  only  then  will  the  positive 
or  negative  results  of  the  digestion  experiments  be  decisive.  For 
a  long  time  I  have  used  no  other  method,  and  I  confess  that  I  have 
always  considered  the  procedure  self-explanatory.     I^ow,  as  hydro- 


DIAGNOSIS  OF  CHRONIC  GASTRITIS.  223 

chloric  acid  is  a  decided  stimulant  for  the  secretion  of  pepsin,  or 
rather  for  the  transformation  of  pepsinogen  into  pepsin,  it  is  advis- 
able to  follow  Jaworski's  suggestion  in  cases  of  deficient  hydro- 
chloric-acid secretion  where  we  wish  to  be  certain  of  the  absence  of 
this  ferment :  200-300  c.  c.  [f  3  vjss.  to  x]  of  diluted  hydrochloric 
acid  [decinormal  HCl  solution]  are  administered  [through  the  stom- 
ach tube  after  having  washed  the  viscus],  and  half  an  hour  later  the 
stomach  is  siphoned.  The  fluid  is  then  tested  as  to  its  digestive 
powers,  and  by  using  suitably  diluted  portions  we  may  obtain  an 
approximttte  idea  of  the  amount  of  pepsin  present.* 

Naturally,  no  tissue  elements  of  the  glandular  parenchjona  are 
to  be  found  in  the  contents  of  a  totally  atrophied  stomach  ;  a  few 
degenerated  round  cells  and  micro-organisms  may  be  all  that  is 
found.  [Fragments  of  tissue  have  been  found  in  the  wash-water  in 
lavage  by  Cohnheim  and  others.]  The  absence  of  hsematemesis  or 
of  blood  in  the  stomach  contents  is  characteristic  of  anadenia.  I 
have  never  encountered  the  latter. 

These  diiferences  will  generally  enable  us  to  distinguish  the 
several  varieties  of  the  disease.  Yet,  as  already  stated,  there  are 
intermediate  forms,  especially  between  the  simple  and  the  mucous, 
which  can  not  be  definitely  classified.  However,  the  greatest  diag- 
nostic difliculty  is  encountered  in  differentiating  atrophy  of  the 
stomach  from  the  cases  of  gastric  neuroses  and  carcinoma,  accom- 
panied by  complete  loss  of  secretion.  From  the  neuroses  it  may  be 
distinguished,  as  a  rule,  by  the  fact  that  these  occur  usually  in  mid- 
dle-aged or  young  persons,  and  that  their  course  is  irregular,  while 
atrophy  occurs  in  older  persons  and  is  permanent. 

The  chemical  differentiation  of  carcinoma  and  atrophy  is  much 
more  difficult — that  is,  where  the  ordinary  symptoms  of  the  former, 
tumor,  swelling  of  the  lymphatic  glands,  cachexia,  and  hsemate- 
mesis,  are  absent ;  because  in  both  hydrochloric  acid,  pepsin,  and 
rennet  may  be  absent.  But,  as  I  have  already  said,  atrophy  leads 
to  a  gradual  extinction  of  the  gastric  functions  without  the  severe 

*  Jaworski.  Zur  Diagnose  des  atrophischen  Magenkatarrhs.  Verhandlungen 
des  vii.  Congresses  fiir  innere  Medicin.  Wiesbaden.  1888.  [A  good  description  of 
this  method  will  be  found  in  Stewart,  Amer.  Jour.  Med.  Sciences,  vol.  ex,  p.  563. — 
Ed.] 


224  DISEASES  OP  THE  STOMACH. 

vomiting  and  gastralgia  whicli  occur  so  often  in  cancer.  Another 
symptom  has  been  of  service  to  me ;  at  all  events,  it  is  also  a  very 
valuable  point  in  the  diagnosis  of  cancer.  I  refer  to  the  bloody 
color  of  the  stomach  contents,  due  to  the  presence  of  altered  blood 
pigment,  which  is  frequently  observed  in  carcinoma,  even  where 
there  has  been  no  hsematemesis.  So  far  as  I  know  at  present,  this 
never  occurs  in  anadenia  of  the  gastric  mucous  membrane. 

Course  and  Prognosis. — The  long  duration  of  chronic  gastritis  is 
indicated  by  its  name.  This  is  especially  due  to  its  tendency  to 
relapses,  or,  more  properly  speaking,  exacerbations  ;  for  even  in 
apparently  cured  cases  the  organ  is  left  in  such  a  sensitive  condi- 
tion that ,  the  slightest  irritation,  or  a  deviation  from  a  sj)ecified 
diet,  may  cause  a  fresh  attack.  Therefore  the  prognosis  of  the  dis- 
ease should  not  be  considered  too  slightingly,  especially  as  in  pro- 
longed cases  atrophy,  an  incurable  and  fatal  lesion,  may  be  devel- 
oped. A  large  number  of  the  cases  which  are  usually  said  to  have 
died  of  old  age  really  perish  from  gastric  atrophy ;  but  it  is  gen- 
erally not  recognized,  since  its  symptoms  are  as  yet  not  well 
known,  and  because  the  macroscopic  changes  in  the  stomach  are 
not  marked.  Finally,  there  is  another  reason  why  the  significance 
of  chronic  gastritis  is  not  to  be  underestimated,  namely,  the  dis- 
turbances of  nutrition  and  the  resulting  deterioration  of  the  tissues 
render  the  organism  less  resistant  toward,  and  more  susceptible  to,  a 
series  of  other  poisons,  of  which  I  shall  only  mention  tuberculosis 
and  acute  articular  rheumatism.  As  certain  as  it  is,  on  the  one 
hand,  that  tuberculosis  leads  to  gastric  catarrh,  so  probable  is  it,  on 
the  other,  that  even  though  the  latter  does  not  produce  the  predis- 
position for  the  former,  yet  if  the  stomach  trouble  is  once  present 
it  favors  and  increases  the  advance  of  the  tubercular  infiltration. 

Treatment. — Our  remedies  must  be  divided  into  three  groups : 
(1)  those  which  aim  to  directly  replace  the  deficient  supply  of  gas- 
tric juice  ;  (2)  those  which  are  to  stimulate  the  depressed  functions 
of  the  organ  ;  (3)  those  which  are  capable  of  counteracting  the  irri- 
tant substances  introduced  from  without. 

The  first  class  includes  the  use  of  hydrochloric  acid,  pepsin,  and  of 


TREATMENT  OP   CHRONIC   GASTRITIS.  225 

the  so-called  peptogenous  substances.  The  therapeutic  employment 
of  the  latter  depends  on  the  well-known  claims  of  Scliiff  and  Herzen 
of  the  effects  of  certain  (peptogenous)  substances  (bouillon,  dextrin, 
breadcrumbs) ;  '■'"  but,  as  I  have  already  shown,  this  peptogenous,  or 
rather  pepsinogenous,  action  of  these  substances  depends  only  on 
the  stimulation  of  the  gastric  glands,  such  as  is  exerted  by  all  kinds 
of  nutritious  substances ;  the  stomach  is  filled  with  active  digestive 
substances,  the  peptic  power  of  which  must  be  of  assistance  to  the 
ingesta  which  are  swallowed  later.  Still,  Dujardin-Beaumetz  f  has 
proposed  an  elixir  peptogene,  which  consists  of  10  parts  of  dextrin, 
20  of  rum,  and  180  of  sugar  water ;  and  Labastide  X  attributes  to 
peptone  enemata  the  power  of  at  once  relieving  obstinate  anorexia 
by  the  administration  of  peptogenous  substances. 

Hydrochloric  acid  is  of  the  greatest  importance  in  the  treat- 
ment of  chronic  gastritis,  because  it  not  alone  replaces  the  deficiency 
in  the  secretion  and  forms  acid  albuminates  so  essential  for  pep- 
tonization, but  also  because  it  prevents  abnormal  fermentation,  or 
lessens  it  if  already  present.  Apparently  in  relation  to  such  fer- 
mentations even  Hebei'den  says,  '"''Potus  acidi  non  semper  nocent 
aegris  acore  ventriculi  laborantibus  nonnunqumn  etiam  auxilio 
suntP  *  Pemberton  says  the  same.  As  this  checking  of  fer- 
mentation is  due  to  hydrochloric  acid  alone,  it  is  wrong  for  some 
writers  to  recommend  lactic  or  citric  acid  instead  of  it,  for  they 
have  no  such  antif ermentative  action.  In  all  cases  where  a  diminu- 
tion or  absence  of  hydrochloric  acid  has  been  determined — i.  e.,  in 
all  cases  of  chronic  gastritis— it  is  therefore  to  be  given,  preferably 
as  the  dilute  hydrochloric  acid  of  the  pharmacopoeia  ||  in  large  quan- 
tities, and  certainly  in  larger  doses  than  have  thus  far  been  recom- 
mended. Jaworski  was  the  first  to  show,  what  daily  experience  has 
since  proven,^  that   considerable   quantities   of   hydrochloric  acid 


*Ewald.  Klinik,  etc..  I.  Theil,  3te  Auflage,  S.  108.— A.  Herzen.  Altes  nnd 
Neues  iiber  Pepsinbildnng,  Magenverdauiing  und  Krankenkost.     Stuttgart,  1885. 

f  Dujardin-Beaumetz.     Journal  de  therap,  1880,  p.  828. 

X  Labastide.     Gazette  d.  hopit.,  1883,  p.  332. 

*  Quoted  by  Budd,  loc.  cit.,  p.  424. 

II  [Acid,  hydrochlor.  dil.  (Ph.  Germ.)  has  25  per  cent  pure  HCl. — Ed.] 

^  Loewenthal  (Berl.  klin.  Wochenschr.,  1892,  No.  47)  went  to  the  unnecessary 
trouble  of  proving  this  over  again. 


226  DISEASES   OP   THE   STOMACH. 

may  be  introduced  into  the  stomach,  without  harm;  therefore,  1 
order  it  in  as  concentrated  a  watery  solution  as  possible — i.  e.,  as 
sour  as  the  patient's  mouth  will  tolerate — to  be  taken  three  or 
four  times,  at  fifteen  minutes'  intervals,  after  the  meal ;  a  glass 
tube  should  be  employed,  as  the  prolonged  use  of  the  acid  affects 
the  teeth.  It  is  still  better  to  pour  200  to  300  c.  c.  [  ^  vij — x]  of  a 
•4  to  '5 -per- cent,  solution  of  HCl  directly  into  the  stomach  tube, 
provided  the  patient  has  become  accustomed  to  the  tube.  I  had 
repeatedly  done  this  with  very  good  success  in  obstinate  catarrhs.* 
Pills  may  also  be  made  with  bolus  alba  (Ph.  Germ.)  [argilla]  and  a 
few  drops  of  dilute  muriatic  acid ;  jQve  or  six  of  these  may  be  or- 
dered at  a  time,  to  be  taken  with  a  glass  of  water.  But  if  one  has 
obtained  a  clear  conception  of  this  subject,  it  will  be  seen  that  these 
small  doses  are  like  pouring  drops  of  water  into  the  sea.  I  have 
prescribed  this  remedy  for  months  at  a  time  without  any  bad 
effects. 

Pepsin  was  for  a  long  time  regularly  prescribed  with  the  muri- 
atic acid,  with  the  pernicious  idea  that  even  if  it  did  not  help,  it 
certainly  did  no  harm.  To-day,  however,  we  know  that  pepsin  is 
present  in  a  very  large  number  of  cases  even  when  free  hydro- 
chloric acid  is  absent,  and  that,  as  shown  by  Jaworski,f  and  as  I  can 
corroborate,  pepsin  can  be  extracted  from  the  glands  of  the  human 
stomach  by  means  of  this  acid.  We  should  therefore  restrict  its 
administration  to  those  cases  in  which  its  absence  can  be  actu- 
ally proved — that  is,  to  cases  of  advanced  mucous  catarrh  and  of 
atrophy.  It  is  then  to  be  given  in  large  doses,  O'S — I'O  gramme 
[gr.  vijss.  to  xv],  preferably  dissolved  in  water  acidulated  with  hy- 
drochloric acid,  fifteen  to  twenty  minutes  after  eating ;  for,  even 
though  small  amounts  of  pepsin  are  said  to  liquefy  large  quantities 
of  albumen,  yet  the  artificial  pepsin  preparations  contain  a  consid- 
erable amount  of  milk  sugar ;  and  further,  only  a  portion  of  the 
pepsin  is  active,  because  a  part  of  it  is  soon  carried  on  into  the  in- 

*  Ewald.  Zur  Therapie  der  Krankheiten  der  Verdauungstraetus.  Bed.  klin. 
Wochenschr.,  1892. 

f  W.  Jaworski.  Die  Wirkung  der  Sauren  auf  die  Magenfunction  des  Mensehen. 
Dentsch.  raed.  Wochenschr.,  1887,  Nos.  36-38.— Also,  Methoden  zur  Bestiminung 
der  Intensitat  der  Pepsinausscheidung.  Miinchener  med.  Wochenschr.,  1887, 
No.  33. 


TREATMENT   OP   CHRONIC   GASTRITIS.  227 

testines.  In  cases  of  complete  absence  of  hydrochloric  acid  it 
would  seem  rational  to  administer  pancreatin  or  papoid."  How- 
ever, experiments  made  under  my  direction,  by  Dr.  Haafewinkel, 
showed  that  the  various  j)reparations  of  pancreatin  which  were 
given  with  the  test  breakfast  had  no  stimulating  effect  on  its  diges- 
tion. 

[If  pepsin  is  to  be  used,  the  best  preparations  are  the  various 
glycerin  extracts  which  have  been  placed  upon  the  market.  It 
ought  to  be  prescribed  alone,  for  if  combined  with  HCl  and  many 
other  substances  which  have  been  recommended,  such  as  alcohol 
(elixirs  and  wines  of  pepsin),  the  activity  of  the  ferment  is  soon  de- 
stroyed. Pineapple  juice  contains  a  proteolytic  ferment  (bromelin), 
and  hence  may  be  of  service  in  chronic  gastritis.f] 

The  object  of  the  second  class  of  remedies  is  to  increase  the 
activity  of  the  glands.  Pre-eminent  in  this  group  is  lavage  of  the 
stomach,  which,  excepting  in  dilatation  of  the  stomach,  has  no- 
where done  more  good  than  in  chronic  gastritis.  This  is  true  of 
the  simple,  and  especially  of  the  mucous,  variety.  It  is  well  to  com- 
bine the  stomach  douche  with  the  lavage  ;  this  is  continued  till  the 
wash- water  runs  off  perfectly  clear,  and  then  a  quantity  of  water  or 
medicated  solution  may  be  left  behind  in  the  stomach. 

At  first  we  use  clear  warm  water,  which  may  be  replaced  at  the 
conclusion  with  an  alkaline  or  antiseptic  solution,  as  the  case  may 
demand.  The  former  is  employed  where  mucus  is  abundant,  the 
latter  for  the  fermentative  processes.  The  great  advantage  of  the 
tube  is  that  we  can  introduce  much  larger  quantities  of  unpleasant 
or  irritating  substances  than  would  be  possible  by  the  mouth,  be- 
cause they  can  be  removed  at  once. 

It  is  best  to  prescribe  the  medicament  which  is  to  be  employed 
in  the  lavage  in  the  form  of  powders,  one  of  which  is  to  be  added 
to  a  litre  [quart]  of  warm,  boiled  water.     Thus  we  may  order : 

*  [Finkler.  Comparative  experiments  between  the  action  of  papoid  and  pepsin. 
Therapeutic  Gazette,  August  15,  1887.  Grote.  Klinisehe  Erfahrungen  iiber  die 
Wirkung  des  Papains  bei  3Iagenkrankheiten.  Deutsch.  med.  Wochensehr.,  Julv 
23,  189G.— Ed.] 

\  [Takadiastase  is  an  amylaceous  ferment  which  has  been  recently  recommended 
to  aid  in  the  digestion  of  starches  in  cases  of  so-called  "  buccal  dyspepsia."  These 
cases  seem  to  me  to  be  forms  of  hyperchlorhydria. — Ed.] 


228  DISEASES   OP  THE  STOMACH. 

Sodii  bicarbonas Y'5  to  10-0  [  §  4  to  -|] 

Sodii  carbonas lO'O  [  3  i] 

Acid,  salicylic! 1*0  to  3"0    [gr,  xv  to  xlv] 

Thymol 0*5  [gr.  vijss.] 

Acid,  boric lO'O  [  ^  ^] 

Sodii  biboras 15-0  to  20*0  [  |  i  to  |] 

Of  tlie  liquid  preparations  we  may  use :  Liq.  argenti  nitras, 
50  c.  c.  [  ^  If]  of  a  2-per-ceiit  solution  may  be  added  to  a  litre 
[quart]  of  distilled  water.*  We  may  also  employ  Aq.  chloroformi, 
lOOO'O  ;  if  we  wish  to  prepare  it  freslily,  we  may  prescribe  : 

:p   Chloroformi 50*0  [  ^  j|] 

Aq 1000-0  [Oij] 

M.  Sig.  :  Sbake  well  several  times  during  the  day  and  use  the 
supernatant  liquid  for  lavage. 

Kresin  may  be  used  in  0-5-1-0-per-cent  solution,  and  is  preferable 
to  creolin  and  similar  preparations  because  its  odor  and  taste  are 
less  marked.  [Hydrogen  peroxide  has  also  been  recommended  by 
some.     I  have  obtained  no  special  results  with  it.] 

Even  after  a  relatively  small  number  (eight  to  ten)  of  washings 
a  marked  improvement  in  the  local  process  and  a  great  relief  to  the 
patient  may  be  observed.  I  could  cite  a  large  number  of  cases  to 
corroborate  this,  but  I  shall  not  do  so,  because  there  is  nothing 
characteristic  about  them ;  yet  1  repeat,  that  cases  which  have  re- 
sisted the  usual  methods  of  treatment  for  months,  and  even  years, 
have  been  greatly  relieved  and  even  cured  by  lavage  in  a  relatively 
short  space  of  time,  this  treatment  having  been  of  course  accom- 
panied by  other  suitable  therapeutic  measures. 

When  the  condition  of  the  patient  prevents  a  systematic  use  of 
the  tube— the  patients  no  longer  object  to  the  much-abused  "  stom- 
ach pump,"  now  that  the  public  is  better  informed  of  the  necessity 
of  the  modern  methods  of  examination  and  treatment  of  gastric 
disorders — I  replace  it  by  ordering  large  quantities,  up  to  half  a  litre 
[pint],  of  a  1-per-cent  solution  of  common  salt  at  42°  C.  [107'5 

*  [Nitrate  of  silver  may  also  be  applied  to  the  gastric  mucous  membrane  with 
Einhorn's  gastric  spray.  (N.  Y.  Med.  Journal,  September,  1892).  The  empty 
stomach  is  washed  out  with  lukewarm  water,  and  §  ^  of  a  i^  to  -^g  per  cent  AgNOs 
is  sprayed. — Ed.] 


TREATMENT   OF   CHRONIC   GASTRITIS.  229 

Falir.],  or  Wiesbaden  Kochhrunnen,  or  warmed  Rakoczy  [Kissiii- 
gen]  water. 

The  action  of  lavage  consists  in  the  removal  from  the  stomach 
of  remnants  of  food  which  have  remained  there  unduly  long,  and 
the  loosening  of  the  mucus  which  adheres  to  its  walls,  partly 
chemically,  partly  mechanically ;  furthermore,  the  introduction  of 
the  tube,  combined  with  the  entrance  and  exit  of  the  water,  in- 
creases the  peristalsis  and  strengthens  the  muscular  activity,  as  well 
as  favorably  influences  the  glands,  or,  as  put  by  Oser,  "  it  produces 
a  healthy  reaction."  The  sodium  chloride  is  certainly  not  without 
value,  notwithstanding  the  fact  that  Pfeiifer  has  shown  that  the 
addition  of  it  in  artificial  digestion  lessens  the  digestive  power.  The 
experiments  of  Braun  and  Griitzner,  as  well  as  of  Boas,  agree  that 
the  addition  of  common  salt  to  the  blood  increases  the  secretion  of 
gastric  juice,  and  seem  to  me,  for  many  reasons,*  to  be  more  con- 
vincing'than  artificial  digestion  experiments.  At  all  events,  the  re- 
sults at  Wiesbaden  and  Kissingen  and  of  daily  practice  disprove  it. 

As  a  stimulant  of  the  glandular  secretion,  we  may  also  employ  in- 
ternal faradization  of  the  stomach  (see  p.  103),  although  the  tonic  ac- 
tion on  the  muscular  fibers  undoubtedly  also  plays  an  important  part. 
This  much  is  at  all  events  certain,  that  I  have  had  perfect  success 
with  this  method  in  a  number  of  obstinate  cases  of  chronic  gastritis. 
It  must  be  added,  however,  that  the  treatment  was  faithfully  given 
several  times  weekly  for  a  long  time,  together  with  appropriate 
drugs  and  diet ;  but  since  the  latter  had  been  previously  used  for 
a  long  time  without  any  pronounced  good  effect,  we  must  accord 
to  the  electricity  the  greater  part  of  the  success  obtained. 

The  most  contradictory  views  have  recently  been  expressed  con- 
cerning the  use  and  action  of  the  so-called  titters  and  carminatives. 
Although  these  substances  formerly  enjoyed  a  high  reputation  as  gas- 
tric stimulants,  yet  the  experiments  of  Tscheltzow,  Jaworski,  Reich- 
mann,  and  Stekhoven  f  show  that  the  bitters  only  have  any  specially 

*  Vide  Ewald,  Klinik,  etc.,  I.  Theil,  3te  Aufl.,  p.  99. 

f  W.  Jaworski.  Experimenteller  Beitrag  znr  Wirkung  unci  therapeutischen 
Anwendung  der  Amara  und  der  Galle.  Zeitschr.  ftir  Therapie,  1886,  No.  28. — 
Reichniann,  Zeitschr.  fur  klin.  Med..  1888,  Bd.  xiv,  p.  177.— Stekhoven.  Weekbl. 
V.  Geneesk.,  1887. — Tscheltzow,  quoted  by  Tawizki,  Deutsch.  Arch,  fiir  klin.  Med., 
Bd.  xlviii,  p.  344. 


230  DISEASES  OF  THE  STOMACH. 

good  effect  upon  the  secretive  and  digestive  powers  of  tlie  stomacli 
when  they  are  taken  some  time  before  the  meal,  and  even  then  the 
effect  on  the  gastric  juice  is  only  slight.  On  the  other  hand,  Terray, 
Marcone,  Tawizki,  and  Ramm,*  partly  from  experiments  on  animals, 
partly  from  observations  on  human  beings,  uphold  the  old  empirical 
notions  that  bitters  have  a  decidedly  good  effect  on  the  motility 
and  secretions  of  the  stomach.  Marcone  asserts  that  when  intro- 
duced into  the  empty  stomach  they  stimulate  the  secretion  of  gastric 
juice  ;  if  administered  with  the  food,  the  period  of  digestion  is  short- 
ened, the  gastHc  juice  increased  in  quantity,  and  the  peristalsis 
heightened.  After  section  of  the  vagi  in  the  neck  this  effect  was 
not  obtained ;  hence  there  must  be  a  direct  action  on  the  mucous 
membrane  of  the  stomach. 

However  all  this  may  be,  all  writers  agree  that  there  is  no 
marked  difference  between  the  various  bitters,  and  that  any  good 
therapeutic  results  which  may  be  obtained  must  be  accepted  accord- 
ing to  the  views  above  mentioned.  My  own  belief  is  that  these 
differences,  which  also  correspond  to  what  is  observed  in  practice, 
are  to  be  explained  according  to  the  intensity  and  extent  of  the  gas- 
tritis and  the  reactive  power  of  the  glandular  parenchyma.  The 
success  of  quassia,  gentian,  kino,  calumba,  chamomile,  vermuth, 
peppermint,  and  of  condurango  bark,  has  been  noted  by  too  many 
and  too  good  observers  than  that  it  should  depend  upon  crude  self- 
deception,  I  have  always  been  satisfied  with  quassia  and  condu- 
rango, although  I  usually  combine  them  with  hydrochloric  acid  in 
such  proportion  that  the  solution  contains  0'2  per  cent  of  pure 
hydrochloric  acid. 

The  following  formulae  may  be  recommended  : 

'^   Cortic.  condurango 30'0  [  ^  j] 

Macera  per  horas  xij  cum  aq.  300*0  [f  ^  x] 

Diger.  lent,  calore  ad  colatur.  150*0  [f  5  v] 

Adde 

Acid,  hydrochlor.  dilut 5*0  [f  3  ji] 

Syrup,  zingiber ad  200*0  [f  ^  vj  3  vj] 

M.     Sig. :  One  tablespoonful  every  two  to  three  hours. 

*  Terray.     Wien.  med.  Woehenschr..  1891,  No.  12. — Marcone.     Riforma  mediea, 
June  8,  1891. — Ramm,  in  Robert's  histor.  Studien  aus  dem  pharmakolog.  Instit. 


TREATMENT  OP  CHRONIC   GASTRITIS.  231 

]^   Tinct.  nuc.  vomic S'O  [f  3  ji] 

Kesorcin  resublimat 10-0  [  3  ijss.] 

Tinct.  gentian 25-0  [f  3  vji] 

Syrup,  simpl ad  200-0  [f  I  vj  3  vj] 

M.  Sig.  :  One  tablespoonful  every  two  to  three  hours. 
An  especial  action  on  the  muscular  tone  has  always  been  at- 
tributed to  nux  vomica,  or  its  alkaloid  strychnine,  and  belladonna, 
especially  in  drinkers  and  persons  with  weak  nervous  systems. 
This  is  undoubtedly  true,  provided  we  substitute  large  doses  for 
the  customary  small  ones.  I  usually  prefer  to  combine  the  tinctura 
nucis  vomicae  with  a  decoction  of  one  of  the  above  stomachics 
in  such  proportin  that  at  least  ten  drops  are  in  each  table- 
spoonful  : 

li  Tinct.  nuc.  vomicae 5-0  [f  3  ji] 

Decoct,  condurango 150"0  [f  5  v] 

M.  Sig. :  Tablespoonful  three  to  four  times  daily,  half  an  hour 
before  taking  food. 

Or  it  may  be  combined  with  belladonna,  as  follows : 

^  Tinct.  belladonnse S'O  [f  3  ji] 

Tinct.  nuc.  vomicae 10*0  [f  3  ijss.] 

Tinct.  castor,  canadensis  * lO'O  [f  3  ijss.] 

M.     Sig. :  Twenty  drops  (!)  six  times  daily. 
We  may  also  follow  the  English  custom  and  give  ipecac  in 
small  doses  of  2  to  3  centigrammes  [gr.  |-  to  -1]  with  the  extract,  nuc. 
vomicae  in  the  same  dose,  ordering  it  in  powders  thrice  daily,  half 
an  hour  before  meals. 

Alcohol  also,  according  to  Klemperer,f  stimulates  the  motility, 
so  that  the  popular  belief  in  the  value  of  "stomach  bitters"  re- 
ceives official  approval,  as  it  were,  although  the  older  investiga- 
tions, as  well  as  the  more  recent  ones  of  Klemperer,  Hugounang, 
Georges,  Katz,  and  many  others,:}:  all  agree  that  it  has  absolutely  no 

zu  Dorpat.,  Bd.  ii,  1890.    Here  an  exhaustive  review  of  the  literature  of  the  bitters 

may  be  found. 

*  [This  preparation  was  officinal  in  the  U.  S.  Pharm.  of  1870.— Ed.] 

f  Klemperer.    Alcohol  und  Kreosot  als  Stomachica.    Zeitschr.  fiir  klin.  Med,, 

Bd.  clxxi,  Supplement,  p.  324. 

X  Georges.    Quelques  experiences  propres  k  eclairer  la  therapeutique  de  Ig.  dys- 

pepsie  gastrique.    Arch,  de  med.,  1890,  No.  1. 
16 


232  DISEASES   OP   THE  STOMACH. 

stimulating  effect  ujjoii  secretion  and  the  peptic  digestion  is  even 
retarded  by  it, 

[The  effect  of  alcohol  on  digestion  has  recently  been  most  elab- 
orately studied  by  Chittenden  and  Mendel.*  Their  results  agree 
with  those  of  E,obert8,f  that  "  in  the  presence  of  less  than  10  per 
cent  of  proof  spirit  (5  per  cent  absolute  alcohol)  there  was  no  ap- 
preciable retardation  of  gastric  digestion.  With  10  per  cent  of 
proof  spirit  retardation  was  only  barely  perceptible,  while  with  20 
per  cent  retardation  was  quite  distinct.  Beyond  this  point  the  in- 
hibitory effect  of  alcohol  increased  rapidly."  In  conclusion,  they 
show  that  the  actual  effects  of  alcohol  on  digestion  can  not  be  de- 
termined  from  the  results  of  the  chemical  changes  alone,  but  only 
when  these  are  combined  with  the  effects  on  secretion,  absorption, 
and  penetration.  "  ]!^ot  until  these  points  have  been  thoroughly 
studied  shall  we  be  able  to  understand  fully  the  action  of  alcoholic 
beverages  on  the  whole  process  of  digestion."] 

Much  has  been  written  about  orexin,  a  derivative  of  chinolin, 
which  Penzoldt  has  introduced  as  a  true  stomachic.;}:  Kronfeld  * 
found  101  favorable  reports  in  176  cases  which  he  could  collect  from 
the  literature.  This  does  not  mean  much,  because  bad  results  are 
not  published,  or,  if  published,  are  referred  to  less  than  the  good 
ones.  Henne  ||  reports  that  digestion  is  delayed  and  even  checked 
by  it.  Although  at  the  start  I  had  a  few  unexpectedly  good  results 
in  improving  the  appetites  of  phthisical  patients,  yet,  although  I 
have  used  it  very  frequently,  I  have,  unfortunately,  found  it  to  be 
very  uncertain  ;  not  infrequently  it  was  a  complete  failure.  Besides 
this,  the  patients  often  complained  of  severe  burning  pains  in  the 
stomach,   "  as   if  they  had   been   poisoned."     Why  more  or  less 


*  [Chittenden  and  Mendel.  The  Influence  of  Alcohol  and  Alcoholic  Drinks 
upon  the  Chemical  Processes  of  Digestion.  Amer.  Jour.  Med.  Sciences,  vol.  cxl, 
1896,  pp.  35,  163,  314,  and  431  et  seg.— Ed.] 

+  [Roberts.    Digestion  and  Diet.    London,  1891,  pp.  115  and  132.— Ed.] 
X  [Penzoldt.     Salzsaures  Orexin,  ein  eehtes  Stomachicum.     Therapeut.  Monats- 
hefte,  Bd.  iv,  1890,  p.  59.     Other  papers  on  this  subject  may  be  found  in  this  vol- 
ume, pp.  287,  374.  496,  and  Bd.  v,  1891,  pp.  203.  309,  364.— Ed.] 

*  Kronfeld.  Wirkungsweise  des  salzsaures  Orexin.  Wiener  klin.  Wochenschr., 
1891,  Nos.  3  and  4. 

II  Henne.  Experimentelle  BeitrSge  zur  Therapie  der  Magenkrankheiten.  In- 
aug.  Dissert,  Bern,  1891. 


TREATMENT  OP  CHRONIC  GASTRITIS.  233 

prompt  effects  should  be  obtained  in  some  cases  and  absolutely  none 
in  others,  I  can  not  explain.  My  own  experience  shows  that  the 
most  failures  were  in  cases  of  nervous  anorexia  (hysteria,  neuras- 
thenia, etc.).  It  is  administered  as  orexin  hydrochlorate  in  pills  of 
O'l  gramme  (gr.  jss.),  3,  4,  and  5  pills  of  which  are  taken  on  three 
successive  days  half  an  hour  before  the  principal  meal.  [My  expe- 
rience with  orexin,  both  the  basic  and  the  hydrochlorate,  has  been 
unsatisfactory.  The  most  recent  report  on  it  is  that  of  Battistini,* 
who  found  it  useful  in  19  out  of  25  cases.] 

Creosote  and  guaiacol  have  undoubtedly  an  exceedingly  good 
effect  on  gastric  digestion  in  many  cases,  which  is  probably  due  to 
the  antifermentative  effect  of  these  preparations ;  but  in  some 
cases,  either  at  the  beginning  or  after  they  have  been  taken  for 
some  time,  they  are  not  borne  well ;  the  burning  pain  in  the  stom- 
ach and  the  constant  repeating  and  offensive  taste  in  the  mouth  ab- 
solutely destroy  the  appetite  instead  of  improving  it.  But  accord- 
ing to  my  own  extensive  experience  with  these  drugs  these  cases  are 
exceptional ;  they  may  be  explained  either  by  the  fact  that  the  dose 
has  been  increased  too  rapidly  or  the  mode  of  administration  has 
been  bad,  thus  allowing  the  creosote  to  come  into  direct  contact  with 
the  mucous  membrane  of  the  stomach.  Creosote  is  best  given  in 
sugar-coated  pills  or  capsules,  each  containing  5  centigrammes  [f 
grain]  creosote  with  1  centigramme  [gr.  ^~\  balsam  of  tolu,  10  of 
which  may  be  taken  daily.  Guaiacol  may  be  taken  in  doses  of  1 
centigramme  [gr.  i-]  several  times  daily.  Henne  f  claims  that  these 
drugs  do  not  have  any  effect  on  the  gastric  juice,  and  attributes  the 
good  effects  which  he  has  had  to  their  antiseptic  qualities. 

The  same  good  effects  may  be  obtained  from  resorcin^  the  value 
of  which  has  so  often  been  urged  by  Andeer.  This  is  a  true  antisep- 
tic, in  spite  of  the  statements  of  Brieger,  Gilberti,  P.  Guttmann,  and 
others  to  the  contrary.  I  can  fully  agree  with  Menche:}:  in  highly 
recommending  it  in  diseases  of  the  digestive  tract  accompanied  by 
fermentation.     It  is  essential  that  the  purified,  white  resublimated 


*  [Battistini.     Therap.  Monatshefte,  December,  1894. — Ed.] 
f  Henne.     Loc.  cit, 

X  Menche.     Das  Resorcin  als  innere  Mittel.  Centralbl.  fiir  klin.  Med.,  1891. 
No.  21. 


234  DISEASES  OP  THE  STOMACH. 

resorcin  which  is  free  from  all  by-products  be  prescribed  ;  it  seems 
to  have  none  of  the  bad  effects  which  have  been  observed  after  ordi- 
nary resorcin.  ^Nevertheless  I  have  once  had  a  case  in  which  black- 
ish-brown urine  was  passed  after  using  it  for  a  short  time,  but  the 
urine  cleared  up  immediately  after  the  drug  was  discontinued.  Ees- 
orcin  is  freely  soluble  in  water  and  alcohol,  and  may  be  prescribed 
with  the  various  infusions  and  tinctures  or  as  a  powder.  Some  re- 
cent favorite  prescriptions  have  been  : 

^   Tinct.  nuc.  vomic 25*0  [f  3  vj;^] 

Kesorcin.  resublimat ^'0  [  3  ji] 

Tinct.  cinchon.  comp 10*0  [f  3  ijss.] 

M.     Sig.  :  Ten  to  fifteen  drops  every  two  hours. 
]^  Resorcin.  resubhmat., 

Bismuth,  subnitrat. aa  lO'O  [  3  ijss.] 

!Natrii  bicarbonat., 

Ext.  rhiz.  calami, 

Sacchar.  alb aa     8-0  [  3  ij] 

M.     Sig.  :  Teaspoonful  every  two  hours. 
These   prescriptions   may  be  varied  by   substituting,  as  may  be 
needed,  rhubarb,  salicylates,  sulphur,  etc. 

[My  own  experience  agrees  entirely  with  the  above.  Although 
I  have  used  the  drug  very  extensively,  only  once  did  I  see  the  char- 
acteristic blackish  urine  which  is  so  familiar  after  using  carbohc  acid. 
I  believe  such  bad  effects  are  due  to  a  decomposition  of  the  resorcin 
by  the  alkalies  which  are  so  often  prescribed  with  it.  It  is  possible 
that  intermediate  bodies,  like  pyrogallic  acid,  etc.,  may  be  set  free. 
Solutions  or  powders  with  alkalies  darken  after  a  short  time,  and 
hence  such  combinations  ought  to  be  avoided.  The  great  value  of 
resorcin  may  readily  be  understood,  if  we  recall  that  its  chemical 
composition  is  almost  identical  with  that  of  carbolic  acid.  It  is  val- 
uable not  alone  as  an  antiseptic,  but  also  as  a  sedative.  Few  drugs 
are  more  valuable  in  gastric  disorders  than  resorcin.  The  doses 
given  are  usually  too  small ;  it  may  safely  be  given  as  high  as  5  to 
10  grains  at  a  dose,  and  should  be  well  diluted  with  water.*] 

"What  is  true  of  resorcin  may  also  be  said  of  salicylic  acid  and 

*  [Manges.    Kesorcin  as  a  Gastro-intestinal  Remedy.   New  York  Polyclinic,  June 
15,  1895,  p.  173.— Ed.] 


TREATMENT  OP  CHRONIC   GASTRITIS.  235 

the  salicylates^  especially  sodium  salicylate  and  bismutli  salicylate. 
The  fact  that  salicylic  acid  is  not  used  more  frequently  in  gastric 
catarrhs  may  be  due  to  the  fact  that  it  is  strongly  irritant  to  the 
gastric  mucosa  and  also  to  the  kidneys ;  while  it  is  claimed — whether 
rightly  or  wrongly,  I  do  not  know — that  bismuth  salicylate  acts  more 
upon  the  intestines  than  upon  the  stomach.  [The  decided  chola- 
gogue  action  of  the  salicylates  renders  them  peculiarly  valuable 
agents  where  disorders  of  the  liver  are  associated  with  the  gastric 
disorders.  Phenol  bismuth  and  betanaphthol  bismuth  (dose  15  to 
30  grains)  are  said  to  be  mostly  decomposed  in  the  stomach,  and 
have  been  proposed  to  replace  bismuth  salicylate.] 

I  have  been  much  less  satisfied  with  the  action  of  carbolic  acid, 
thymol,  benzoic  acid,  naphthalin,  and  naphthol ;  this  is  probably  due 
to  the  fact  that  their  disagreeable  after-effects  prevent  the  admin- 
istration of  sufficiently  large  doses. 

On  the  other  hand,  in  catarrhs  associated  with  gastralgia,  I  have 
found  chloral  hydrate  to  be  of  very  great  value  because  it  is  an  anti- 
fermentative  as  well  as  a  sedative.  The  three  cases  of  agoraphobia 
cited  above  were  all  cured  with  chloral.  I  order  a  tablespoonful  of 
a  3-  to  5-per-cent  solution  to  be  taken  every  two  hours.  The  same 
is  true  of  chloroform^  the  high  antiputrefactive  value  of  which  has 
been  shown  by  Salkowski.  It  is  best  administered  in  doses  of  2  or 
3  drops  in  a  teaspoonful  of  water  or  claret  every  2  or  3  hours. 

I  wish  to  call  attention  once  more  to  the  antifermentative  action 
of  a  systematic  use  of  hydrochloric  acid. 

It  is  also  well  known  that  the  symptoms  due  to  fermentation 
may  be  relieved  or  lessened  in  a  short  time  by  sufficient  doses  of 
alkalies,  as  bicarbonate  of  soda  in  5-  to  10-grain  doses  alone  or  com- 
bined with  rhubarb  or  bismuth  ;  but  it  is  simply  palliative,  and 
favors  rather  than  opposes  the  cause  of  the  process.  [An  excellent 
antacid  for  occasional  use  is  the  tablet  proposed  by  Roberts.*  Each 
tablet  consists  of 

]^  Calcii  carbonat,  prsecipit gr.  iijss. 

Magnes.  carbonat gr.  ijss. 

Sodii  chloridi gr.  j 

The  tablets  are  to  be  allowed  to  dissolve  slowly  in  the  mouth,  the 

*  [See  Sir  William  Roberts.    British  Med.  Journal,  1889,  vol.  ii,  p.  373.— Ed.] 


236  DISEASES  OP  THE  STOMACH. 

copious  flow  of  alkaline  saliva  being  thus  induced.  Concerning  tlie 
action  of  bicarbonate  of  soda  in  gastric  disorders  many  papers  have 
recently  been  written ;  of  these  the  most  important  is  that  of  Reich- 
mann.*  After  very  careful  experiments  he  concludes  that  it  acts 
as  an  antacid  upon  the  acid  already  secreted,  but  that  it  in  no  way 
influences  the  secretory  power  of  the  stomach,  even  if  used  for  a 
long  time.] 

The  proper  use  of  antifermentatives  also  puts  an  end  to  the 
formation  of  gas,  and  hence  it  is  unnecessary  to  have  recourse  to 
the  use  of  the  more  than  questionable  drugs  recommended  to  absorb 
gas.  The  use  of  charcoal  is  utterly  irrational ;  it  has  recently' been 
brought  into  commerce  m  the  form  of  "  charcoal  cakes  "  ;  the  char- 
coal becomes  moist  in  the  stomach,  and  in  that  condition  its  absorp- 
tive powers  for  gas  are  entirely  lost. 

[The  popular  use  of  charcoal  has  been  ably  defended  in  a  recent 
prize  essay  by  Wild,f  who  has  made  a  careful  laboratory  study  of 
it.  Although  not  possessing  any  antiseptic  properties,  yet  his  ex- 
periments showed  that  it  may  be  useful  either  by  oxidizing  the  chem- 
ical substances  formed  daring  abnormal  decomposition  or  the  toxins 
produced  by  pathogenic  organisms.  "  This  action  may  be  direct  or 
indirect  through  the  aerobic  processes  of  putrefaction,  and  it  is  pos- 
sible that  a  supply  of  oxygen  contained  in  the  charcoal  may  modify 
the  pathogenic  organisms  themselves,  and  render  them  or  their  prod- 
ucts less  virulent.  The  power  of  charcoal  to  remove  alkaloids  from 
solutions  is  worth  considering,  as  certain  toxins  and  ptomaines  are 
possibly  of  this  nature.  It  may  thus  prevent  auto -intoxication  from 
the  alimentary  canal."  It  may  be  given  in  froni  2  to  6  teaspoonf uls 
or  more  daily.  Wood  charcoal  absorbs  much  more  gas  than  animal 
charcoal.] 

However,  the  best  treatment  of  fermentation,  if  at  all  pro- 
nounced, is  lavage  of  the  stomach,  the  details  of  which  will  be  dis- 
cussed in  the  chapter  on  Dilatation  of  the  Stomach. 

[Turck  :{:  has  recently  suggested  the  use  of  his  gyromele  (revolv- 

*  [Reichmann.     Boas'  Archiv.,  Bd.  i,  p.  44. — Ed.] 

f  [Wild.  Medical  Chronicle,  1896,  No.  4,  p.  401.  Abstracted  in  N.  Y.  Medical 
Journal.  1896,  vol.  Ixiii,  p.  463.— Ed.] 

$  [Turck.  Wiener  med.  Wochenschr.,  1895,  Nos.  1  and  2. — N.  Y.  Medical  Jour- 
nal, November  23,  1895,  p.  648.    Medical  News,  April  4,  1896,  p.  373.— Ed.] 


TREATMENT   OP   CHRONIC   GASTRITIS. 


237 


ing  sound)  (Fig.  32)  in  the  treatment  of  chronic  gastritis.  The  in- 
strument consists  of  a  stomach  tube  inside  of  which  is  a  flexible  cable 
(3) ;  to  the  lower  end  of  the  latter  is  attached  a  sponge  (4)  covering 
a  spiral  spring  {d)  which  can  be  removed  and  changed  ;  the  sponge 
may  be  protruded  from  or  withdrawn  into  the  stomach  tube.     The 


[Fig.  32. — Turck's  gyromele.] 

stomach  tube  and  cable  are  attached  to  a  hand  piece  by  which  the 
latter  can  be  made  to  rotate  very  rapidly.  The  instrument  is  intro- 
duced (with  the  sponge  withdrawn  up  to  the  tube)  just  like  an  ordi- 
nary stomach  tube  ;  the  sponge  is  pushed  out  by  dejDressing  the  long 
handle  and  is  made  to  revolve  rapidly  by  turning  the  crank.  Water 
may  be  introduced  through  the  small  lateral  tube  which  is  armed 
with  a  pinchcock.  The  movable  gag  (b)  is  placed  between  the  pa- 
tient's teeth.  The  revolving  sponge  catches  up  any  adherent  mucus 
and  food  fragments  and  cleanses  the  mucous  membrane  just  as  the 
ancients  sought  to  cleanse  the  stomach  with  their  gastric  brushes. 
By  .changing  the  position  of  the  tube  the  various  parts  of  the  stom- 
ach may  be  cleansed.  The  instrument  may  also  be  used  to  obtain 
bacteriological  cultures  of  the  stomach  contents.  Turck  claims  excel- 
lent results  for  his  instrument  in  the  treatment  of  chronic  gastritis.] 
The  hydriatic  measures — cold  rubbings,  douches  to  the  epigas- 
trium (highly  prized  by  the  ancients,  and  known  as  cataclysmus), 
and  massage — are  also  useful.  Apparently  irrational  is  the  use  of 
alkaline  waters,  for  example,  as  recommended  by  G.  See,  half  an 
hour  before  meals.  But  since  Jaworski  has  shown  that  carbonic- 
acid  waters  strongly  stimulate  the  chemical  activity  and  absorption, 
their  action  may  probably  be  explained  in  that  way ;  on  the  other 
hand,  they  neutralize  where  the  secretion  of  acid  is  marked.  How- 
ever, all  these  procedures  are  useless  unless  they  are  combined  with 
a  careful  regulation  of  the  diet. 


238  DISEASES  OP  THE  STOMACH. 

The  regulation  of  the  diet  of  the  dyspeptic  begins  in  the  mouth. 
"We  have  already  seen,  in  the  etiology  of  chronic  gastritis,  that  two 
important  factors  were  the  care  of  the  teeth  and  slow  eating — that 
is,  a  sufficient  disintegration  and  insalivation  of  the  food  in  the 
mouth.  Although  the  care  of  the  mouth  is  now  much  more  gener- 
ally observed  than  formerly,  yet  only  too  often  do  we  still  find  ex- 
amples of  shocking  neglect.  I  will  not  mention  poorly  cleansed 
teeth  covered  with  tartar,  caries,  diseased  alveoli,  or  inflamed  gums 
with  a  thick  whitish-green  coating  of  desquamated  epithelium,  fungi, 
cocci,  and  remnants  of  food  between  the  teeth.  These  are  so  promi- 
nent that  they  are  noticed  at  once  ;  and  we  ought  always  to  recom- 
mend the  patients  (and  healthy  persons  as  well)  to  brush  the  teeth 
after  each  meal.  Less  apparent  is  the  layer  of  filth  which  covers 
the  plates  of  artificial  teeth,  or  the  broken-off  stumps  beneath  them. 
Kaczarowski  has  exaggerated  these  conditions,  but  he  is  certainly 
right  in  many  cases.  Thus,  not  long  ago,  a  man  consulted  me  for 
a  typical  mucous  catarrh ;  he  had  a  false  upper  plate,  and  naively 
admitted  that  he  never  removed  his  teeth  at  night,  and  only  cleansed 
them  about  every  third  day.  The  plate  was  covered  with  a  dirty- 
white  coating  consisting  of  numerous  fungi  and  masses  of  cocci, 
while  the  hard  palate  was  markedly  reddened  and  dotted  with  small 
aphthous  ulcers.  In  the  slimy  stomach  contents  there  were  small 
brown  streaks  which  consisted  of  granular  blood  pigment  and  num- 
berless fungi  and  yeast-cells.  The  patient's  complaints  were  rela- 
tively slight,  and  began  only  after  his  treatment  by  the  dentist.  In 
this  case  the  swallowed  bacteria  unquestionably  kept  up  a  constant 
state  of  irritation  of  the  gastric  mucous  membrane. 

[Attention  lias  already  been  directed  to  Turck's  work  on  the  im- 
portance of  the  naso-pharynx  in  the  treatment  of  chronic  gastritis 
(page  207).  Hemmeter  *  has  devised  a  tongue  brush  for  removing 
the  debris  which  accumulates  at  the  root  of  the  tongue.] 

The  importance  of  eating  slowly  has  been  told  thousands  of  times. 
A  striking  example  of  this  is  the  fact  that  many  people  with  weak 
stomachs  while  on  a  journey  can  digest  the  poor  food  of  the  hotels, 
because  they  have  nothing  else  to  do  and  stay  a  long  time  at  the 
table,  yet   they  suffer  from  the    carefully  prepared  and    selected 

•■  [Hemmeter.     N.  Y.  Medical  Journal,  December  28,  1895,  p.  836.— Ed.] 


TREATMENT  OF  CHRONIC  GASTRITIS.  239 

dislies  at  home,  which  are  rapidly  consumed  while  the  mind  is  occu- 
pied with  business  cares.  Upon  similar  psychical  grounds  is  based 
the  observation  that  many  dishes  are  sometimes  well  borne  by  dys- 
peptics, while  at  other  times  they  cause  great  discomfort,  according 
to  the  mental  or  bodily  condition.  Many  persons  also  have  a  marked 
idiosyncrasy  toward  certain  dishes,  and  for  others,  again,  an  entirely 
voluntary  and,  as  it  were,  unjustifiable  tolerance.  In  the  course  of 
practice  you  will  frequently  meet  patients  who  assert  that  they  can 
tolerate  rich  mayonnaises,  pastries,  tough  or  fat  meat,  as,  for  exam- 
ple, lobster  or  goose,  but  who  suffer  intensely  after  a  cup  of  milk  or 
bouillon.  As  a  result,  every  physician  who  has  much  to  do  with 
diseases  of  digestion  sooner  or  later  ceases  to  forbid  individual 
dishes,  but  will  be  guided  by  the  patient's  experience.  There  is  a 
certain  amount  of  truth  in  the  saying  of  G.  See,  ^^  En  France  on 
jpeut  bien  soumettre  un  menu  au  malacle,  en  Alleinagne  on  Vy  sou- 
metP  One  can  only  indicate  the  fundamental  principles  of  dietetics 
concerning  the  form  and  amount  of  food.*  Still,  it  is  of  great  im- 
portance to  give  the  patient  a  daily  bill  of  fare  in  which  the  time  of 
meals  and  the  kmd  and  exact  amount  of  food  are  explicitly  stated. f 
But  in  doing  this  we  should  follow  the  patient's  tastes  as  far  as  pos- 
sible, and  should  arrange  regular  meals  at  two  to  three  hours'  in- 
tervals. 

That  what  is  allowed  should  be  given  in  the  most  digestible  con- 
dition, is  self-evident.  Therefore  forbid  hard-boiled  eggs,  meat  with 
very  tough  fibers  and  tendons,  the  flesh  of  too  old  animals  or  of 
those  which  have  just  been  slaughtered,  in  which  the  post-mortem 
formation  of  acids  has  not  yet  had  an  opportunity  to  soften  it.  For 
the  same  reason  warmed  meat  is  to  be  forbidden,  also  that  which 
contains  too  much  fat,  like  pork,  fat  portions  of  lamb,  fat  fowl,  fish 

*  [This  subject  is  very  well  discussed  in  Sir  William  Roberts's  work  on  Dio:es- 
tion  and  Diet,  London,  1891,  pp.  160  et  seq.  A  good  review  of  the  chapter  on  this 
topic  will  be  found  in  the  American  Journal  of  the  Medical  Sciences,  1891,  vol.  ci, 
p.  397.— Ed.] 

■f  [Boas  has  recently  protested  vigorously  against  the  custom  of  giving  the  pa- 
tient a  printed  diet  list,  as  too  much  freedom  is  thus  allowed.  Nevertheless,  with 
a  little  care  such  lists,  if  properly  prepared,  will  be  found  useful.  The  best  set  of 
detachable  diet  lists  which  has  yet  been  published  is  that  of  J.  B.  Thomas,  Diet 
Lists  and  Sick-Room  Dietary.  Published  by  W.  B.  Saunders,  Philadelphia,  1895. 
—Ed.] 


240  DISEASES  OF  THE  STOMACH. 

and  moUusks  (salmon,  carp,  turbot,  eel,  lobster,  crabs,  oysters  *), 
sausages,  smoked  fisb  like  flounder,  herring,  eel,  sprats,  lamprey, 
etc.  Under  the  direction  of  Penzoldt,  Gigglberger,f  with  tlie  aid 
of  the  stomach  tube,  has  experimented  on  himself  with  various  arti- 
cles of  food  prepared  in  as  many  ways  as  possible.  His  results 
practically  agree  with  those  of  Beaumont.;}:  According  to  him,  meat 
remains  in  the  stomach  between  two  hours  and  twenty-five  minutes 
(stewed  calf-brain)  and  five  hours  and  twenty-five  minutes  (roast 
mutton).  In  general,  roasted  meats  remain  somewhat  longer  in  the 
stomach  than  stewed.  It  is  scarcely  necessary  to  mention  that  white 
meats  like  veal,  poultry,  and  young  game,  venison,  etc.,  are  easy  to 
digest.  Eggs,  even  when  raw,  are  badly  borne,  much  more  fre- 
quently than  would  be  suspected  ;  scrambled  eggs  and  omelettes  are 
to  be  excluded  at  once.  Heavy  cheeses  are  also  indigestible  ;  hence 
the  old  proverb  that  they  are  gold  in  the  morning  but  lead  at  night. 
I  also  consider  that  bouillon  from  red  meats  is  not  indicated,  not  on 
account  of  its  albuminoids,  but  because  the  high  percentage  of  salts 
may  irritate  the  gastric  mucosa ;  this  is  not  the  case  with  bouillons 
made  from  white  meats.  Gelatinous  soups  and  jellies  made  from 
calves'  feet,  calves'  heads,  ox  tails,  etc.,  are  bland  and  nutritious  on 
account  of  their  gelatin,  which  is  easily  oxidized  and  saves  the  bodily 
fats  from  combustion.  Among  irritant  ingesta  may  also  be  included 
strong  acids,  like  vinegar,  strong  condiments,  and  alcohol  in  concen- 
trated form  as  liqueurs.  Indirectly  injurious — that  is,  by  their 
products  of  decomposition — are  the  fats,  and  hence  oils  and  fatty 

*  R.  H.  Chittenden.  On  the  Relative  Digestibility  of  Fish  Flesh  in  the  Gastric 
Juice.  Amer.  Chemic.  Jour.,  vol.  vi,  No.  5.  Chittenden  places  oysters  almost  at 
the  foot  of  his  table.  This  is  not  absolutely  correct.  Not  long  ago  I  artificially 
digested  some  oysters  and  found  that  they  were  digested  more  rapidly  and  com- 
pletely than  soft-boiled  egg  albumin.  Raw  and  not  fried  oysters  should  be  al- 
lowed ;  they  should  be  chewed,  and  not  swallowed  whole.  The  greater  part  of  an 
oyster  consists,  as  is  well  known,  of  glycogen  and  a  digestive  ferment,  hepatic  dias- 
tase. In  chewing,  both  substances  are  brought  together,  so  that  the  glycogen  is 
immediately  converted.  By  frying,  the  ferment  is  destroyed  and  the  usefulnes's  of 
the  glycogen  is  also  lessened,  just  the  same  as  happens  when  the  oysters  enter  a 
stomach  which  contains  too  much  HCl.  Hence  oysters  are  especially  well  digested 
when  there  is  a  deficiency  in  the  secretion  of  HCl.     Roberts,  loc.  cit. 

t  X.  G-igglberger.  Ueber  die  Dauer  der  Magenverdauung  von  Fleischspeisen. 
Inaug.  Dissertation.     Erlangen,  1886. 

X  Vide  Ewald.  Klinik.  etc.  I.  Theil.  3te  Auflage,  pp.  114  et  seq.  [Elaborate 
tables  are  given  as  to  the  digestibility  of  the  various  articles  of  diet. — Ed.] 


TREATMENT  OP  CHRONIC  GASTRITIS.  241 

sauces  should  not  be  found  on  tlie  dyspeptic's  table.  A  substitute 
for  meat  may  be  found  in  the  peptone  preparations  and  peptone 
chocolate  ;  *  the  latter  is  expensive,  but  may  easily  be  prepared  at 
home  by  boiling  some  cocoa  free  from  fat,  or  even  chocolate,  and 
adding  some  peptone  or  meat  peptone. 

On  the  other  side  of  the  scale  of  nutritious  substances  are  the 
carbohydrates,  including  everything  from  pure  starch  preparations 
to  the  nitrogenous  flours,  vegetables,  fruits,  and  legumes.  Their 
digestion  is  easy,  provided  that  in  their  preparation  as  much  starch 
as  possible  has  been  changed  into  dextrin,  and  the  thick  consistency 
of  the  dough  formed  by  mixing  flour  and  water  has  been  got  rid  of 
by  heat  and  drying  in  the  air.  Therefore  all  freshly  baked  articles 
are  to  be  avoided  ;  on  the  other  hand,  it  explains  the  digestibility  of 
the  various  flours,  and  soups,  jellies,  etc.,  prepared  from  them ;  also 
of  vegetables  and  fruits  when  they  are  freed  from  their  cellulose  and 
softened,  and  in  the  case  of  the  former  when  prepared  with  a  mini- 
mum amount  of  fat.  But  all  kinds  of  cabbage  are  to  be  avoided, 
because  the  carbohydrates  contained  in  them  are  especially  prone  to 
fermentation. '  This  is  also  true  of  the  legumes,  and  hence  mashed 
peas  and  lentils  are  usually  poorly  borne.  On  the  other  hand,  the 
so-called  leguminous  flours,  which  may  now  be  bought  in  many 
forms,  constitute  a  good  diet,  of  which,  however,  the  patients  usually 
tire  after  a  time.  But  it  must  never  be  forgotten  that  all  foods 
with  carbohydrates  very  easily  undergo  fermentation  on  account  of 
the  sugar  which  they  contain  ;  consequently  they  must  be  used  with 
caution  in  all  atonic  conditions  of  the  stomach. 

Milk  occupies  an  intermediate  place  among  the  above-mentioned 
substances  ;  theoretically  it  ought  to  be  the  best.  But  in  practice  it 
is  either  rejected  entirely  or  is  borne  only  for  a  short  time  by  many 
patients ;  however,  it  may  be  given,  cooked  or  raw,  sweet  or  sour, 
or  with  soda,  lime  water,  or  rum.  Koumyss  and  matzoon  are  well 
borne  by  most  persons  ;  some,  however,  can  only  take  them  for  a 
short  time.  It  must  also  not  be  forgotten  that  an  exclusive  milk 
diet  is  a  kind  of  slow  starvation,  and  that  to  live  on  milk  alone 

*  [Mosquera's  beef  cacao  is  a  similar  preparation  ;  a  tablespoonful  of  the  powder 
is  added  to  a  cup  of  hot  milk,  and  is  boiled  five  minutes  like  ordinary  cocoa.  It  is 
quite  palatable.     Somatose  may  also  be  highly  recommended. — Ed.] 


242  DISEASES   OP  THE   STOMACH. 

would  require  mucli  larger  quantities  than  the  capacity  of  the  stom- 
ach would  allow.  Still,  a  high  nutritive  value  can  be  given  to  milk 
by  adding  the  so-called  milk  powder — i.  e.,  milk  which  has  evapo- 
rated to  dryness  and  pulverized  ;  of  this,  100  grammes  [3^  ounces] 
represent  about  one  litre  [quart]  of  milk. 

Finally,  dyspeptics  must  not  forget  the  general  rule  never  to 
fully  satisfy  their  appetite,  but  to  stop  as  soon  as  they  feel  the  first 
sensation  of  satiation,  and  to  allow  sufiiciently  long  intervals  to  in- 
tervene between  meals. 

Fluids  are  not  to  be  taken  too  hot  nor  too  cold,  nor  in  too  large 
quantities,  since  they  unnecessarily  dilute  the  gastric  juice.  Dys- 
peptics should  also  avoid  all  strongly  carbonated  waters  and  those  in 
which  fermentation  readily  occurs,  since  the  stomach  becomes  dis- 
tended and  the  blood  surcharged  with  carbonic-acid  gas  ;  for  there 
are  very  few  cases  in  which  its  stimulating  effects  neutralize  these 
disadvantages.*  According  to  experiments  performed  on  himself, 
Eichenberg  f  claims  that  small  quantities  of  alcoholic  beverages 
(cognac,  alcohol)  lessen  the  time  of  digestion  a  httle  {^  to  -^  of  the 
total  time),  just  as  50  to  60  drops  of  the  officinal  diluted  HCl  do.  As 
bland  beverages  we  may  use  the  time-honored  orgeat,  rice  water, 
and  decoctions  of  hops,  salep,  and  barley. 

It  is  self-evident  that  in  diet  Hsts  we  can  only  give  general  direc- 
tions and  the  maximum  quantities  beyond  which  the  patients  must 
not  go.  For  the  exact  selection  and  preparation  of  the  various  arti- 
cles of  diet  I  would  refer  to  what  has  already  been  said,  and  to 
"Weil's  Tisch  fiir  Magenkranke  or  Heyl's  Kochbuch  fiir  Kranken- 
kiiche.:}: 

Although  it  is  important  to  regulate  the  patient's  diet,  yet  it  is 
equally  essential  to  see  that  the  ordinary  diet  is  resumed  at  the 
proper  time.     Most  patients  are  only  too  glad  to  resume  this  as  soon 


*  [These  remarks  apply  with  even  greater  force  to  the  use  at  meals  of  alkaline 
carbonated  waters  like  Vichy,  Seltzers,  etc. — Ed.] 

f  Eichenberg.  Ueber  die  Aufenthaltsdauer  der  Speisen  im  Magen  bei  Zufuhr  Ton 
Salzsauer,  Alkohol,  und  andere  Eeizmitteln.  Dissert.  Erlangen,  1891.  (The  writer 
experimented  on  himself.) 

t  [For  additional  data  upon  the  dietetics  of  chronic  gastritis,  see  Thompson's 
Practical  Dietetics,  1896,  pp.  496  et  seq. ;  Burney  Yeo,  Hare's  System  of  Therapeutics, 
1891,  vol.  i,  pp.  646  et  seg.— Ed.] 


TREATMENT  OF  CHRONIC  GASTRITIS.  243 

as  possible  ;  yet  there  are  many  anxious  patients,  of  wliom  we  shall 
speak  later  when  discussing  neurasthenia,  who  allow  themselves  to 
run  down  by  remaining  unnecessarily  long  on  a  restricted  diet,  so  that 
the  original  catarrh  of  the  stomach  is  followed  by  nervous  dyspepsia 
or  a  general  weakness  which  can  only  be  combated  by  an  energetic 
change  of  diet. 

That  the  regulation  of  the  diet  must  be  combined  mth  attention 
to  general  hygiene  need  hardly  be  mentioned  in  our  times.  The 
care  of  the  skin  and  lungs — in  short,  the  care  to  obtain  pure  air — 
constitutes  the  most  important  part  not  alone  of  the  prophylaxis, 
but  also  of  the  treatment,  of  nearly  all  chronic  diseases.  But  it  is 
in  cases  of  chronic  gastric  catarrh  that  much  harm  is  done,  be- 
cause most  patients  think  they  have  done  their  duty  in  attending 
to  a  few  dietetic  details,  and  therefore  find  no  harm  in  spending 
night  after  night  in  a  hot  atmosphere  contaminated  with  gas, 
crowded  rooms,  smoke-filled  saloons,  etc.  The  dyspeptic's  pro- 
gramme should  always  include  active  bodily  exercise,  long  walks, 
horseback  riding,  baths,  sometimes  combined  with  douches,  gymnas- 
tic exercises,  especially  those  which  call  the  abdominal  muscles  into 
action  ;  and  as  most  persons  do  not  carry  out  these  exercises  for  a 
long  time  unless  there  is  some  object  in  view,  they  should  be  taken 
as  sport  or  massage,  Rowing  is  a  specially  valuable  exercise,  and 
with  the  present  sliding  seats,  as  shown  anatomically  by  Mitan,* 
offers  admirable  exercise  for  every  muscle.  It  is  to  be  regretted 
that  women  can  not  indulge  in  this  as  much  as  men,  yet  home  gym- 
nastics, massage,  daily  walks  and  rides  can  accomplish  much  good. 
'•'■Maximegue  qua  superiores  partes  moveat,  quod  genus  in  omnibus 
stomachi  vitiis  aptisshnum  est^''  says  Celsus  ;  yet  it  would  be  even 
better  to  bring  the  body  into  moderate  action  but  not  overexertion. 
[The  bicycle  has  afforded  a  happy  solution  of  the  above  problem. 
Its  rational  use  is  followed  by  the  most  excellent  results  in  this  class 
of  cases.]  f 

*  Mitan.  Das  Rudern,  eine  heilgymnastische  Uebung,  Inaug.  Dissertation. 
Berlin,  1883. 

f  [Those  who  are  interested  in  the  medical  aspects  of  the  bicycle  may  consult  an 
exhaustive  study  by  Mendelsohn  in  Deutsch.  med.  Woehensehr.,  1896,  Nos.  18  to  25. 
An  extended  discussion  of  this  paper  will  be  found,  ibid.,  Vereinsbeilage,  April  2, 
1896  d  seg.— Ed.] 


244  DISEASES  OP  THE   STOMACH. 

[In  some  cases  it  is  equally  important  to  prescribe  rest ;  persons 
with  enfeebled  digestion  are  often  benefited  by  lying  down  for  a 
short  time  after  eating.] 

Finally,  some  special  points  in  the  treatment  still  require  dis- 
cussion. 

Where  gastralgia  resist  all  ordinary  forms  of  treatment  with  the 
various  opiates  they  may  be  temporarily  reheved,  preferably  by  a 
hypodermic  injection  of  morphine.  Hyoscyamus,  hydrocyanic  acid, 
and  belladonna,  as  well  as  chloroform  water  (1  to  200),  have  also  been 
recommended  for  this  purpose.  I  have  found  the  following  com- 
bination very  useful : 

^   Morphinse  hydrochloratis 0'2  [gr.  iij] 

Cocain.  hydrochloratis 0"3  [gr.  v] 

Tinct.  belladonnse 5-0  [f  3  ji] 

Aq.  amygdalae  amarse 20'0  [f  3  v] 

M.  Sig.  :  Ten  to  fifteen  drops  every  hour.  Where  the  pains 
are  very  severe,  three  doses  of  ten  drops  each  within  an  hour. 

Budd  attributes  a  sedative  action  to  Fowler's  solution,  taken  half 
an  hour  before  eating ;  while  Siebert  *  has  even  come  to  the  conclu- 
sion that  with  the  use  of  arsenic  the  pains  of  nervous  or  catarrhal 
gastralgia  disappear  in  a  few  days,  but  persist  where  it  is  due  to  an 
ulcer. 

Germain  See  has  spoken  very  highly  of  the  use  of  calcium  and 
bromide  salts  and  of  extract,  cannabis  indicse  in  gastralgias  of  all 
kinds,  and  has  laid  especial  stress  upon  the  fact  that  it  acts  only 
locally  on  the  mucous  membrane  of  the  stomach,  and  not  upon  the 
general  nervous  system.  I  can  not  agree  with  this  sweeping  recom- 
mendation. It  is  true,  I  have  obtained  analgesic  effects  from  its 
use  in  some  patients,  for  I  have  used  it  in  the  form  of  an  infusion 
for  more  than  twenty  years  ;  occasionally  excellent  results  were  ob- 
tained with  the  officinal  extract,  using  as  much  as  one  decigramme 
[gr.  jss.]  at  a  dose  ;  others  were  attacked  with  severe  cerebral  symp- 
toms, like  intoxication  and  headache  ;  in  still  others  it  had  no  effect 
whatever. 

[I  can  fully  agree  with  Mackenzie's  recommendation  of  canna- 

*  Siebert.     Ueber  Magenschmerz  und  Magengeschwiir.    Deutsche  Kliiiik,  No. 
10, 1853. 


TREATMENT   OF   CHRONIC   GASTRITIS.  £45 

bis  indica  in  the  treatment  of  gastralgia  and  enteralgia.*  The  vary- 
ing reports  are  due  not  to  the  drug  but  to  the  preparation  employed. 
The  unpleasant  effects  due  to  idiosyncrasies  may  be  avoided  by  be- 
ginning with  small  doses  and  gradually  increasing  until  the  point  of 
tolerance  is  reached.  Mackenzie  prefers  the  tincture  for  rapid  ef- 
fects, the  extract  being  more  suitable  for  slow  and  continuous  use.] 

Codeine,  especially  codeine  phosphate,t  acts  much  better.  I 
prescribe  it  either  in  drops  like  the  morphine  drops  above  mentioned 
(replacing  the  morphine  by  codeine,  but  in  double  the  quantity,  0-4 
[gr.  vj],  or  as  powder  with  bismuth  subnitrate,  extract  of  belladon- 
na, etc.  : 

'^  Codeinse  phosphatis 0-02-0-015  [gr.  i-i-] 

Bismuthi  subnitratis 0*3      [gr.  v] 

Sacchari  lactis 0-2      [gr.  iij] 

M.     Sig.  :  Tal.  dos.  every  two  hours. 

It  is  superior  to  morphine  because  it  retards  the  intestinal  peri- 
stalsis much  less,  and  its  use  is  very  rarely  followed  by  nausea. 

Purgatives. — Irregularity  of  the  bowels  plays  a  very  important 
part  in  all  forms  of  chronic  gastritis.  In  the  early  part  of  this  work 
I  have  called  attention  to  the  close  connection  between  the  intes- 
tines and  the  stomach,  and  have  repeatedly  pointed  out  that  many 
so-called  stomach  troubles  are  really  in  the  intestines.  Although  I 
shall  reserve  a  detailed  description  of  these  conditions  for  the  por- 
tion of  this  work  devoted  to  the  diseases  of  the  intestines,-;}:  yet  the 
use  of  purgatives  must  be  considered  here,  since  they  not  alone  re- 
lieve the  intestinal  disturbances,  but  also  directly  aid  the  passage  of 
the  stomach  contents  into  the  intestine  by  securing  prompt  evac- 
uations. In  the  same  way  those  drugs  which  act  as  cholagogues 
also  increase  the  peristalsis  of  the  intestines,  and  hence  empty  the 
bowels.  In  the  vast  majority  of  cases  of  chronic  gastritis  we  must 
combat  constipation  and  not  diarrhoea. 

We  may  at  once  eliminate  one  group  of  purgatives,  the  vegetable 
oils,  of  Avhich  the  typical  example  is  castor  oil ;  it  irritates  the  stom- 

*  [Stephen  Mackenzie.  On  some  Classes  of  Cases  in  which  Indian  Hemp  is  of 
special  Service.     Medical  Week,  1894,  p.  457. — Ed.] 

f  [Codeine  phosphate  is  often  preferable  to  codeine  on  account  of  its  solubility ; 
the  ordinary  dose  is  0*1  [gr.  jss.]  ;  the  daily  dose  is  0*4  [gr.  vjj. — Ed.] 

X  [This  portion  of  this  work  has  not  yet  been  published. — Ed.] 


246  DISEASES  OP  THE  STOMACH. 

ach  and  nauseates  most  patients  even  when  given  in  an  emulsion. 
Although  it  has  undoubtedly  been  very  useful  in  many  cases  of  so- 
called  stomach  catarrhs,  yet  it  is  just  in  these  cases  that  the  real 
trouble  is  in  the  intestines  and  not  in  the  stomach,  and  the  injurious 
effects  on  the  latter  are  more  than  counterbalanced  by  its  beneficial 
action  on  the  former.  I  have  even  been  able  to  demonstrate  experi- 
mentally the  disturbing  effect  of  oil  on  the  chemical  processes  of 
digestion.*  Saline  cathartics  are  also  only  to  be  given  when  an 
action  on  the  small  intestines  is  desired  ;  then  the  sulphate-of-soda 
mineral  waters  are  to  be  used,  or,  as  these  are  usually  insufiicient, 
the  salt  itself  in  substance.  An  excellent  remedy  is  sulphate  of  soda 
in  combination  with  rhubarb  and  carbonate  of  soda ;  it  is  the  old 
solamen  hypochondriacuin  of  Kleist  which  has  been  recommended 
by  Leube  : 

^  Pulv.  rad.  rhei 20*0  [  3  v] 

Sod.  sulphat 10-0  [  3  ijss.] 

Sod.  carbonat., 

Sod.  bicarbonat aa     5-0  [gr.  Ixxv] 

M.  Sig.  :  At  bedtime,  |^  to  1|-  teaspoonfuls  in  a  glass  of  warm 
water,  as  may  be  necessary. 

According  to  the  individual  indication  this  may  be  changed  and 
magnesia  usta,  or  tartaric  acid,  or  sulphate  of  potash  may  be  added ; 
or,  as  I  prefer,  it  may  be  combined  with  bismuth  salicylate,  benzo- 
naphthol,  and  extract,  nuc.  vomic.  (in  atony  of  the  stomach  with 
tendency  to  flatulence  from  intestinal  fermentation) : 

5)  Extr.  nuc.  vomicae 0*5  [gr.  vijss.] 

Bismuthi  salicylatis, 

Benzonaphthol aa  lO'O  [  3  ijss.] 

Pulv.  rad.  rhei IS'O  [  §  ss.] 

IS^atrii  sulphatis., 

Potassii  bitartratis aa     8'0  [  3  ij], 

l^atrii  bicarbonatis 5-0  [  3  ji] 

M.     Sig. :  One  teaspoonful  every  two  hours. 
Here  I  may  also  mention  cream  of  tartar,  Eochelle  salt,  or  tartrate 
of  soda  (Ph.  Germ.)  ;  they  may  be  given  in  effervescing  lemonades, 

*  Ewald  und  Boas.  Zur  Physiologie  und  Pathologie  der  Verdauung.  II.  Vir- 
chow's  Archiv,  Bd.  civ. 


TREATMENT   OF  CHRONIC   GASTRITIS.  247 

in  powder  witli  washed  sulphur,  or  in  decoctions  with  the  vegetable 
aperients  spoken  of  in  the  next  paragraph. 

Yegetahle  Aperients. — The  mildest  of  these  are  the  various 
fruits  which  owe  their  efficacy  to  their  vegetable  acids.  The  use  of 
stewed  prunes  at  night  before  retiring  is  well  known  ;  less  known  is 
a  mixture  of  two  parts  of  prunes  and  one  part  of  dried  figs  ;  the 
taste  is  agreeable  and  the  cathartic  action  is  mild.  Among  the  true 
laxatives  rhubarb  stands  pre-eminent,  and  in  fact  in  all  its  various 
proportions  it  is  a  very  valuable  aid  to  dyspeptics  ;  yet  it  has  one 
great  disadvantage,  that  its  action  is  temporary  and  is  followed 
by  obstinate  constipation.  !Next  to  it  stand  tamarinds,  then  senna, 
buckthorn,  European  centaury  (Herba  centaurii.  Ph.  Germ.),  tarax- 
acum, coriander,  fennel,  etc.,  some  as  extracts,  others  as  teas  ;  of  the 
latter  the  best-known  preparation  is  the  so-called  Hamburg  tea. 
Senna  sometimes  causes  nausea  and  cohc  ;  this  may  be  avoided  by 
using  an  alcoholic  extract  (extract,  sennse  fluid.),  or  by  adding  some 
aromatic  spirits  of  ammonia  or  tincture  of  cardamom.  Cascara  sa- 
grada,  which  has  been  so  extensively  used  recently  (50  to  80  drops 
of  the  fluid  extract  at  night),  is  a  mild  and  at  first  a  certain  remedy, 
but  like  the  rest  of  this  class  it  loses  some  of  its  effects  in  time.* 
Extract,  fab.  calabaric.  (Ph.  Germ.)  [ext.  physostigmatis,  U.  S.  Ph.] 
0'05  [gr.  f  ]  with  lO'O  [  3  ijss.]  of  glycerin  has  been  highly  praised 
by  some,  but  according  to  my  experience  is  very  uncertain. 

Aloes  act  especially  on  the  large  intestines,  either  alone  or  com- 
bined with  jalap,  colocynth,  or  scammony.  English  writers  also  con- 
sider it  a  stomachic  and  give  it  especially  with  calomel,  to  which,  as 
is  well  known,  a  cholagogue  as  well  as  a  cathartic  action  has  been 
attributed.  But,  as  Eutherford  has  shown  that  podophyllin  is  also 
a  cholagogue,  and  as  it  has  the  advantage  over  calomel  of  having 
none  of  its  after-effects,  I  prefer  to  use  it  with  aloes,  etc.,  instead  of 
calomel. 

Enemata  also  deserve  mention  ;  they  may  consist  of  warm  water 

*  [This  drug  may  also  be  used  as  a  stomachic  as  well  as  a  laxative. 

5  Tinct.  nucis  vomicis 10*0  [  3  ijss.] 

Ext.  cascaras  sagradse  fluidi, 

Elix.  aurantii aa    40*0  [  3  x] 

Aquam ad  120-0  [  §  iv] 

M.    Sig. :  Teaspoonful  fifteen  minutes  before  eating. — Ed.] 
17 


248  DISEASES  OP  THE  STOMACH. 

alone  or  with  salt,  soap,  decoction  of  senna,  castor  oil,  and  the  like. 
It  is  an  old  rule,  originally  given  by  Trousseau,  that  they  should 
never  be  given  immediately  after  a  meal,  since  they  may  then  easily 
cause  severe  diarrhoeal  discharges  instead  of  easy  movements ;  but 
it  is  only  recently  that  attention  has  been  called  to  the  fact  that  no 
hard-rubber  syringes  should  be  introduced  into  the  rectum ;  instead, 
a  soft,  flexible,  thick  rubber  tube,  v^^ith  one  opening  below  and  sev- 
eral laterally,  should  be  passed  quite  high  up,  and  the  fluid  permit- 
ted to  enter  or  force  its  way  slowly.  Enemata  are  of  especial  value 
where  the  large  intestine  is  relaxed  ;  they  soften  the  hard  fsecal 
masses  which  accumulate  in  the  sigmoid  flexure  and  descending 
colon,  and  they  also  gently  stimulate  the  muscular  fibers  of  the 
lower  segment  of  the  intestine.  Upon  the  latter  also  depends  the 
action  of  the  injections  of  small  quantities  of  glycerin  (which  con- 
stitutes the  active  ingredient  of  the  so-called  "  Oydtmann's  purga- 
tive ")  and  of  the  glycerin  suppositories  which  are  made  of  glycerin 
and  any  easily  melting  substance.  Small  enemata  of  about  300-500 
c.  c.  [  ^  x-xvj]  of  pure,  slightly  warmed  ohve  oil  often  have  an  ex- 
cellent, mild  laxative  action  where  other  forms  of  injections  have  no 
effect  at  all,  or,  if  they  do  act,  only  cause  unsatisfactory  watery  stools 
with  much  tenesmus  and  abdominal  pain.  I  have  used  them  fre- 
quently, and  can  indorse  the  very  favorable  reports  of  Kussmaul  and 
Fleiner.*  As  long  as  the  enemata  operate  (i.  e.,  as  long  as  we  are 
only  dealing  with  the  so-called  torpidity  of  the  lower  bowel)  they 
are  the  best  and  mildest  means,  and  the  bad  results  attributed  to 
their  prolonged  use,  such  as  causing  catarrh  of  the  intestines,  occur 
in  very  few  cases.  Dilatation  of  the  rectum  after  the  use  of  too 
large  enemata  is  much  more  to  be  feared,  and  patients  ought  to  be 
warned  against  this  possibility.  Although  they  usually  lose  their 
effect  after  a  time,  yet  I  know  patients  who  have  successfully  used 
them  daily  for  years. 

Finally,  I  must  not  neglect  to  state  that  a  number  of  cases  of 

*  Fleiner.  Ueber  die  Behandlung  der  Constipation  mit  grossen  Oelklystieren. 
Berl.  klin.  Wochenschr.,  1893.  No.  3.  [These  oil  enemata  are  especially  valuable  in 
cases  of  so-called  spastic  constipation.  Such  cases  may  readily  be  recognized  by 
the  passage  of  small,  very  hard  scybalce  and  by  the  failure  of  the  ordinary  cathar- 
tics. The  latter  make  matters  worse,  because,  instead  of  relaxing  the  spasm  of  the 
intestines,  they  only  increase  it. — Ed.] 


TREATMENT   OP   CHRONIC   GASTRITIS.  249 

cliroiiic  gastritis  can  not  be  cured  with  the  so-called  stomach  reme- 
dies, but  require  treatment  for  the  primary  disease.  These  are 
especially  the  gastric  catarrhs  which  occur  in  pulmonary,  cardiac, 
and  renal  diseases,  and  those  appearing  during  the  course  of  chloro- 
sis. But,  as  the  gastric  symptoms  sometimes  constitute  the  most 
prominent  part  of  the  patient's  complaints,  it  not  infrequently  hap- 
pens that  these  persons  are  for  a  long  time  treated  for  the  stomach 
trouble,  till  a  thorough  examination  reveals  the  real  condition,  and 
the  proper  treatment  of  this  relieves  the  gastric  symptoms. 

Mineral  Springs. — The  drinking  of  mineral  waters,  either  at  the 
springs  or  at  home,  constitutes  an  important  part  of  the  treatment 
of  chronic  gastritis.  Drinking  the  water  at  home  is  only  an  expe- 
dient, and  will  never  replace  the  great  advantages  of  a  residence  at 
the  spa  with  all  its  adjuvants ;  the  mental  and  bodily  rest  and  in- 
vigoration,  the  doles  far  niente  of  life  at  the  springs,  the  constant 
warning  against  dietetic  errors — all  these  are  lacking.  This  is  true, 
even  though,  so  far  as  these  points  are  concerned,  many  well-situ- 
ated people  could  just  as  well  take  the  cure  at  home.  But,  in  spite 
of  every  care  in  filling  and  sending,  bottled  mineral  waters  never 
have  the  invigorating  freshness  nor  the  strength  of  the  bubbling 
spring. 

For  the  local  treatment  of  stomach  troubles  the  following  four 
classes  of  mineral  waters  are  of  most  importance  : 

1.  Pure  salines. 

2.  Salines  with  a  large  amount  of  carbonic-acid  gas. 

3.  Alkaline  salines  in  which  the  proportion  of  sodium  chloride 
and  carbonic-acid  gas  is  much  less  than  that  of  intermediate  salts. 

4.  Alkaline  and  alkaline  -  muriatic  {cdhaliscJi  -  nfiuriatische) 
waters.* 

*  The  following  springs  may  serve  as  types  of  these  classes  : 

(1)  Wiesbaden  {Kochbrunnen). 

Sodium  chloride 6"83 

Calcium  chloride 0'47 

Calcium  carbonate 0'43 

Carbonic-acid  gas 0-5  c.  c.  to  the  litre. 

(2)  Kissingen  {Rahoczy). 

Sodium  chloride S'SS 

Calcium  chloride 0'28 

Calcium  carbonate 1'06 

Carbonic-acid  gas 1392-0  c.  c.  to  the  litre. 


250  DISEASES  OF   THE   STOMACH. 

Unfortunately,  I  must  confess  that  we  know  very  little  of  the 
action  of  these  mineral  waters  upon  the  stomach,  because  the  criteria 
upon  which  their  effects  are  judged  are  based  directly  upon  the  in- 
fluence on  the  intestines,  and  only  indirectly  take  cognizance  of  the 
stomach.  Just  at  present  this  position  is  rendered  still  more  aggra- 
vating because  the  experimental  researches  of  Pf eift'er  *  and  Jawor- 
ski  have  strongly  shaken  our  belief  in  the  influence  of  Glauber's 
salt  on  stomach  disorders.  Jaworski,  as  is  well  known,  has  con- 
cluded, from  his  investigations,  that  Carlsbad  water  stimulates  the 
gastric  secretion  only  in  the  beginning,  and  when  taken  in  small 
quantities  ;  but  if  consumed  for  a  longer  time  it  lessens  it  markedly, 
may  flnally  cause  it  to  disappear,  and  may  even  lead  to  atrophy 
of  the  glandular  parenchyma.f  At  my  request.  Dr.  Sandberg,  of 
Marstrand,  has  investigated  these  striking  results.  Consecutive  ex- 
aminations were  made  on  ten  patients  during  a  four  to  five  weeks' 
treatment  at  Carlsbad  ;  the  result  was  that  in  half  of  them  the  acid- 
ity was  somewhat  lessened,  in  the  others  increased  ;  and  the  lessened 
acidity  was  just  in  those  patients  who  had  had  a  high  acidity  before 
beginning  the  treatment.  But  as  we  know  that  the  acidity  is  sub- 
ject to  very  great  variations  in  the  same  persons,  too  much  weight 
must  not  be  laid  upon  the  above  results,  especially  as  an  apprecia- 
ble change  was  not  found  in  the  peptic  power  nor  in  the  action  of 
rennet. 

For  the  influence  of  common-salt  mineral  waters  on  digestion 


(3)  Carlsbad  (Muhlhrunnen). 

Sodium  sulphate.  ...    2-39 

Sodium  carbonate 1'27 

Sodium  chloride 1'02 

Carbonic-acid  gas 1-27  c.  c.  to  the  litre. 

(4)  Urns  (Kesselbrunnen). 

Sodium  carbonate 1'99 

Calcium  carbonate 0'22 

Sodium  chloride I'O 

Carbonic-acid  gas 553-2  c.  c.  to  the  litre. 

[For  further  information  concerning  these  and  other  springs,  see  George  E. 
Walton.  Mineral  Springs  of  the  United  States,  etc.,  1883.— Hayem  and  Hare. 
Physical  and  Natural  Therapeutics,  1895. — Ed.] 

*  E.  Pfeiffer.  Balneologische  Studien  iiber  Wiesbaden.  Wiesbaden,  1883,  chap- 
ter on  "  Kochsalz  oder  Glaubersalz  1 " 

t  W.  Jaworski.  Ueber  die  Wirkung  des  Carlsbader  Wassers  auf  die  Magendarm- 
function.     Deutseh.  Arch,  fiir  klin.  Med.,  Bd.  xxvii. 


TREATMENT   OF  CHRONIC  GASTRITIS.  251 

I  refer  to  what  was  said  on  page  228,  and  add  tliat  Boas  *  has 
methodically  observed  the  changes  in  the  secretion  of  gastric  juice 
while  taking  warm  saline  waters ;  after  three  to  four  weeks  he 
noticed  a  decided  improvement  in  the  secretion  and  a  coincident 
disappearance  of  the  symptoms.  The  action  of  the  saline  waters 
(sodium  chloride)  depends  chiefly  on  a  stimulation  in  the  secretion 
and  absorption  and  an  increase  in  the  metabolism.  This  is  also  true 
of  the  alkaline  saline  waters,  yet  it  seems  to  be  more  pronounced  in 
the  waters  with  sodium  chloride  than  those  with  sodium  sulphate. 
The  latter  and  the  alkaline  waters  have  such  a  high  percentage  of 
alkali  that  they  can  act  as  antacids.  All  possess  the  property  of  dis- 
solving mucus.  The  saline  waters  stimulate  the  stomach's  activity, 
the  alkaline  saline  act  principally  on  the  intestines  and  hver.  The 
simple  mechanical  action  of  washing  out  the  stomach  is  common  to 
them  all. 

But  while  it  is  true  of  the  saline  and  alkaline  springs  that  they 
can  not  have  any  bad  effect  on  the  general  system,  or,  as  the  layman 
says,  "  they  are  not  powerful,"  yet  this  is  often  the  case  to  a 
marked  degree  with  the  sodium-sulphate  waters,  and,  especially  in 
nervous  and  antemic  persons,  they  may  cause  an  increase  in  the  irri- 
tative manifestations  or  the  signs  of  depression.f  Therefore  we 
ought  never  to  send  patients  with  pronounced  neuroses  of  the  stom- 
ach to  these  springs,  nor  even  allow  them  to  drink  any  of  these 
waters.  For  them  we  must  recommend  a  general  tonic  treatment 
which  may  vary  with  the  individual :  sometimes  only  a  stay  in  high 
mountainous  districts  ;  others  need  the  seashore  ;  others,  again,  re- 
quire a  hydropathic  establishnaent  with  all  its  paraphernalia  ;  in  still 
others,  mud  or  brine  baths,  together  with  small  doses  of  an  alkaline 
muriatic  water,  are  indicated.  To  this  class  belong  the  great  group 
of  nervous  dyspeptics,  the  patients  with  atony  of  the  muscular  fibers 
of  the  stomach  upon  a  nervous  predisposition.  In  this  respect  my 
experience  tells  me  that  much  harm  is  done,  and  every  year  from  a 

*  J.  Boas.  Verhandlungen  des  Vereiiis  fiir  innere  Med.  zu  Berlin,  November 
5,  1888. 

f  By  way  of  addition  I  may  observe  that  I  find  that  so  experienced  a  physician 
as  Cordes  (loc.  cit.,  p.  535)  expresses  himself  thns:  "On  this  occasion  I  wish  to  warn 
most  emphatically  against  sending  irritable,  weak  patients  to  the  sodium-sulphate 
springs  ;  for  they  operate  badly  in  every  case,  because  the  reflexes  proceeding  from 
the  stomach  and  intestines  of  themselves  are  very  pernicious." 


252  DISEASES  OP  THE  STOMACH. 

number  of  patients  I  hear  the  same  complaint,  that  they  were  sent 
to  Carlsbad  on  account  of  chronic  catarrh  of  the  stomach,  but  that 
,  they  had  borne  the  treatment  very  badly.  Carlsbad  and  Marienbad 
are  frequently  these  patients'  greatest  enemies.  The  high  elevation 
of  Tarasp  causes  it  to  occupy  an  intermediate  position ;  Kissingen, 
"Wiesbaden,  Homburg,  ISTauheim,  Franzensbad,  etc.,  or  the  sparkling 
soda  springs  like  Yichy,  Ems,  I*s^euenahr,  Bilin,  etc.,  are  more  indif- 
ferent, and  may  at  times  be  beneficial  on  account  of  the  change  of 
life  and  the  other  well-known  accessories  of  watering-place  life. 

On  the  other  hand,  experience  has  shown  that  the  alkaline-saline 
and  the  alkaline  springs  (to  say  a  few  words  in  anticipation  on  the 
treatment  of  the  gastric  neuroses)  are  very  beneficial  in  conditions 
of  hyperacidity  or  hypersecretion.  The  very  successful  use  of 
Carlsbad  water  in  ulcer  of  the  stomach  is  now  much  more  readily 
understood,  since  we  know  that  the  ulcer  is  in  many  cases  accom- 
panied by  hyperacidity,  and  that  the  mineral  water  not  alone  mo- 
mentarily neutralizes  this  (just  as  in  cases  of  hypersecretion),  but 
also  that  it  may  actually  lessen  the  activity  of  the  secretion.  A 
similar  effect  might  also  be  produced  by  the  purely  alkaline  waters, 
but  they  have  not  yet  been  used  much  for  this  purpose.  Finally, 
the  sodium-sulphate  waters  are  to  be  used  in  those  cases  in  which 
the  stomach  is  only  secondarily  involved  from  disturbances  of  the 
liver  and  the  intestines. 

However,  the  saline  waters  are  indicated  in  all  cases  of  catarrh 
with  lessening  of  the  secretion,  either  with  or  without  the  produc- 
tion of  mucus.  Here  we  may  use  the  simple  sodium  chloride  wa- 
ters where  the  patient  is  otherwise  well,  and  only  the  gastric  and 
intestinal  secretions  are  to  be  augmented  ;  the  sparkling  sodium- 
chloride  waters  are  useful  where  we  desire  the  stimulating  effects 
of  the  carbonic-acid  gas,  and  where,  by  moderate  catharsis  and  the 
use  of  the  brine  as  such,  the  metabolism  may  be  increased. 

Finally,  all  waters  which  are  to  act  on  the  stomach  are  borne 
better  warm  than  cold.  The  stereotyped  directions  to  walk  after 
drinking  this  or  that  water  in  the  morning  on  an  empty  stomach 
will  do  for  the  majority  of  patients,  but  by  no  means  for  all.  The 
waters  do  not  agree  with  some  when  taken  in  this  way,  but  will 
be  well  borne  if  taken  while  still  in  bed  or  later  in  the  morning. 


TREATMENT  OP  CHRONIC   GASTRITIS.  253 

provided  we  do  not  suddenly  upset  the  patient's  routine  mode  of 
living.  There  are  still  others  who  can  only  proceed  gradually  to 
take  the  actual  "  cure."  Therefore  I  frequently  j)rescribe  a  pre- 
liminary course  of  some  other  water  at  home  before  the  patient  goes 
to  the  springs  ;  for  examj)le,  if  Carlsbad  has  been  recommended,  I 
advise  taking  small  quantities — say  ^  to  -|-  litre  [quart]— of  Wies- 
baden Kochhmnnen  water. 

In  the  above  I  have  simply  given  the  general  indications  for 
choosing  springs ;  for  further  details  one  may  consult  the  text- 
books on  balneology,  and  to  the  admirable  treatise  of  Leichtenstern 
in  Ziemssen's  Handbuch  der  allgemeinen  Therapie.*  I  need  hardly 
indicate  how  much  is  left  for  individualizing  by  noting  the  equip- 
ment of  the  different  resorts,  such  as  mud  and  iron  baths,  mild  effer- 
vescing iron  springs,  medico -mechanical  [for  instance,  like  Zander's 
system]  and  electrical  treatment,  etc.  These  details  must  be  attended 
to,  lest  a  stereotyped  method  of  treatment  be  employed,  and  that 
the  individual  indications  may  be  properly  looked  after ;  in  other 
words,  the  treatment  must  be  adapted  to  the  patient,  not  the  pa- 
tient to  the  treatment. 

It  is  unquestionable  that  the  treatment  will  be  much  more  suc- 
cessful if  the  diagnosis  of  gastric  catarrh  is  exactly  defined  into  one 
of  the  three  varieties — simple,  mucous,  or  atrophic  catarrhal  gas- 
tritis.f  This  can  only  be  done  by  employing  the  chemical  methods, 
the  use  and  success  of  which  have  been  greatest  in  this  field  where 
they  were  at  first  least  expected. 

Finally,  it  is  of  equal  unportance  to  both  physician  and  patient 
that  in  the  selection  of  a  suitable  watering-place  for  the  latter,  the 
former  should,  if  possible,  know  the  place  recommended  from  his 
own  personal  observation.  Here,  again,  we  must  individualize,  for 
even  if  the  analyses  of  two  mineral  springs  are  almost  identical,  yet 
it  does  not  therefore  follow  that  they  are  equally  well  adapted  to 
the  same  class  of  patients.  The  other  adjuvants  of  the  place  must 
be  considered,  and  to  know  the  character  of  the  physician  to  whom 
we  intrast  our  patients  is  not  unimportant. 

*  [Vol.  IV  of  American  translation,  New  York,  1885.— Tr.] 
f  Ewald.     Der  chronische  Magenkatarrh  und  seine  Behandlung  an  den  Heil- 
quellen.     Deutsch.  med.  Zeitung,  March  3,  1889. 


CHAPTEK   YI. 

[mechanical]  insufficiency  and  dilatation  of  the  stomach. 

As  I  have  already  stated  [page  90],  there  is  no  absolute  stand- 
ard for  the  normal  size  of  the  stomach,  and  its  capacity  stands  in 
no  relation  whatever  to  the  size  of  the  individual.  We  can  only 
speak  of  an  absolute  dilatation  of  the  stomach  when  it  exceeds  the 
given  capacity  in  round  numbers  of  1,600  to  1,Y00  c.  c.  [53  to  5Y  fl. 
oz.].  But  the  stomach  may  be  actually  much  smaller  and  yet  be 
relatively  dilated  for  the  individual.  Furthermore,  as  Kussmaul 
and  Rosenbach  *  have  already  shown,  there  are  very  large  stomachs 
which  exert  no  disturbing  influence  on  digestion,  so  that  they  are 
discovered  accidentally  while  making  some  other  examination.  I 
therefore  distinguish  between  the  large  stomachy  megalogastria,  and 
the  enlargement  of  the  stomach,  gastric  dilatation  or  gastrectasis, 
which  in  turn  is  to  be  divided  into  an  acute  or  subacute  and  a 
chronic  form.  Megalogastria  may  lead  to  dilatation,  but  is  not  a 
pathological  occurrence.  Thus  it  amounts  to  an  anatomical  condi- 
tion, while  the  nature  of  dilatation  is  that  of  a  functional  disturb- 
ance, combined  with  a  progressive  anatomical  J9r(9c^,s5. 

Accordingly,  I  would  define  dilatation  of  the  stomach,  or  gas- 
trectasis, as  that  condition  of  the  stomach  in  which  the  clinical 
symptoms  of  disturbance  of  the  gastric  functions  proceed  from  an 
enlargement  of  that  organ ;  megalogastria,  however,  is  the  congeni- 
tal or  acquired  large  stomach,  the  functions  of  which  are  compen- 
sated. Persons  with  large  stomachs  may  have  catarrhal  gastritis, 
etc.,  but  this  does  not  mean  that  they  have  dilatation  as  it  is  under- 
stood clinically,  although  they  are  more  disposed  to  this  condition 
than  are  others. 


*  0.  Rosenbach.     Der  Mechanismus  und  die  Diagnose  der  Mageninsufficienz. 
Volkraann's  Sammlung  klinische  Vortrage,  No.  153,  p.  8. 

254 


DIAGNOSIS  OF   GASTRECTASIS.  255 

Germain  See*  also  distinguishes  between  simple  dilatation, 
wliicli  may  exist  for  a  long  time,  or  even  permanently,  without 
creating  any  disturbance  and  dilatation  with  dyspepsia — i.  e.,  that 
condition  which  we  commonly  regard  as  gastric  dilatation,  by  which 
we  do  not  mean  simply  a  large  stomach,  but  that  there  is  at  the 
same  time  a  morbid  disturbance  of  its  function.  Megalogastria  and 
gastrectasis  have  frequently  been  confounded  with  each  other.  An 
entirely  different  condition,  if  I  may  anticipate,  is  gastric  insuffi- 
ciency— Westphalen's  relative  dilatation,  Rosenbach's  relative  gas- 
tric insufficiency — which  indeed  may  and  frequently  does  lead  to 
the  symptoms  of  gastrectasis,  yet  does  not  have  the  anatomical 
basis  of  the  dilated  stomach,  but  is  a  functional  disturbance  occur- 
ring in  the  most  varied  conditions  of  size  of  the  organ.f 

We  possess  the  following  diagnostic  aids  for  the  recognition  of 
the  large  or  dilated  stomach :  X 

1.  Inspection. — With  relaxed  and  thin  abdominal  walls  we  fre- 
quently see  the  left  hypochondriac  region  and  a  larger  or  smaller 
portion  of  the  right,  according  to  the  extent  to  which  the  stomach 
is  filled  with  air  or  ingesta,  bulge  out  like  a  hemisphere  or  balloon, 
beginning  just  below  the  free  margin  of  the  ribs.  The  lower  border 
of  this  swelling  crosses  the  mid-line  on  a  level  with  the  umbilicus, 
or  below  this,  between  it  and  the  symphysis.  At  times  there  is  only 
a  lower  projection  present,  with  a  troughlike  depression  between  it 
and  the  free  border  of  the  ribs,  which  is  caused,  as  a  rule,  by  the 
long  axis  of  the  stomach  assuming  a  more  or  less  vertical  position ; 
occasionally,  however,  it  maybe  produced  by  the  region  of  the  lesser 
curvature  becoming  collapsed,  while  the  fundal  zone  is  inflated  or 
filled  with  ingesta.  In  the  former  case  the  lesser  curvature  runs 
parallel  to  the  spinal  column  in  the  middle  line,  or  even  to  the 
left  of  it,  and  in  highly  marked  degrees  of  this  condition  it  only 
passes  to  the  right  on  a  level  with  the  umbihcus,  so  that  even  the 
pancreas  may  be  felt  between  the  margin  of  the  liver  and  the 
stomach,  and  may  be   mistaken  for  a  gastric   tumor.     Peristaltic 


*  Germain  See.     Du  regime  alimentaire.     Paris,  1877,  p.  280. 
f  [An  excellent  discussion  of  this  subject  will  be  found  in  Riegel.  XJeber  Megalo- 
gastrie  und  Gastrectasie,  Deutsch.  med.  Wochensehr.,  April  13,  1894,  p.  333.— Ed.] 
X  [See  also  p.  SO  et  seq.—  Ed.] 


256 


DISEASES  OP  THE  STOMACH. 


waves  may  travel  over  the  stomacli  from  left  to  right,  either  in 
constant  succession  or  as  the  result  of  external  mechanical  irrita- 
tion ;  antiperistaltic  motions  may  also  be  observed  (Bamberger,* 
Cahn,f  Glax:|:).     [See  Fig.  33].     If  we  inject  air  into  the  stomach. 


[Fig.  33. — Photograph  showinu'  tumor  caused  liy  ililated  stonuicJi,  and  also  undulatory  .waves 
of  peristalsis.  The  crosses  are  placed  on  the  three  prominent  waves.  The  letter/ indi- 
cates the  depression  on  the  lesser  curvature.     (Osier.)  ] 

these  conditions  become  still  more  marked,  and  the  gradual  appear- 
ance of  the  viscus  as  it  becomes  distended  produces,  as  a  rule,  a 
very  characteristic  picture.  The  epigastrium,  which  before  had 
been  sunken  in,  now  projects   forward,  so  that  we  may  usually, 

*  L.  Bamberger.  Krankheiten  des  ehylopoetisehen  Systems.  Erlangen,  1855, 
S.  325. 

t  A.  Cahn.  Antiperistaltische  Magenbewegungen.  Deutsch.  Archiv  f.  klin. 
Med.,  Bd.  xxxv,  S.  402. 

X  A.  Glax.  Ueber  peristaltische  und  antiperistaltische  Unruhe  des  Magens. 
Pester  med.  chirurg.  Presse,  J  884. 


DIAGNOSIS  OF  GASTRECTASIS.  257 

although  not  always,  distinguish  dilatation  from  gastroptosis  (see 
page  89).  In  electric  transillumination  of  the  stomach  we  see  a 
broad  illuminated  zone  extending  from  the  left  of  the  navel  down 
to  the  suprapubic  or  left  inguinal  regions.  [See  Fig.  15.]  In 
advanced  dilatation  the  body  is  usually  emaciated,  the  abdominal 
walls  are  relaxed  and  shghtly  sunken,  and  the  false  ribs  on  the  left 
side  are  raised  like  wings.  The  skin  is  dry,  pale,  and  somewhat 
tawny. 

[Inspection  is  a  means  of  diagnosis  which  is  very  much  neg- 
lected. Its  great  value  may  be  appreciated  by  bearing  in  mind 
that  Osier,*  in  10  out  of  13  cases  of  gastric  dilatation,  was  able  to 
make  the  diagnosis  from  mere  inspection.  An  excellent  idea  of 
what  is  seen  on  inspection  of  the  abdomen  when  the  stomach  is 


[Fig.  34. — Frotile  view  of  abdomen  of  woman,  sixty-five  years  old,   showing  the  tumor 
caused  by  dilated  stomach.     From  photograph  taken  during  life.     (Osier.)] 

dilated  may  be  obtained  from  Figs.  33,  34,  and  35.  The  peristaltic 
waves  are  well  shown  in  Fig.  33 ;  when  present — which  occurs 
much  more  frequently  than  is  generally  supposed — they  are  a  great 
aid  in  diagnosis.  The  force  of  the  waves  may  be  increased  by  flap- 
ping the  abdomen  with  a  wet  towel  or  rubbing  the  skin  with  a 
lump  of  ice.     They  are  not  visible  in  Figs.  34  and  35,  as  the  dilata- 

*  [Osier.  Lectures  on  the  Diagnosis  of  Abdominal  Tumors,  1895,  p.  23.  This 
excellent  work  should  be  studied  by  all  who  would  attain  any  proficiency  in  ab- 
dominal diagnosis. — Ed.] 


258 


DISEASES   OF  THE  STOMACH. 


tion  in  tliis  was  so  great  that  there  was  paralytic  distention  of  the 
stomach.] 

2.  Percussion. — Should  any  suspicion  of  dilatation  exist,  it  is 
best  before  percussing  to  first  distend  the  stomach  with  air.  The 
double  bulb  ought  to  be  alone  used  for  this  purpose,  for  I  have 


[Fig.  35.- 


Anterior  view  of  same  case  as  Fig.  34,  showing  tumor  caused  by  dilatation  of 
stomach.     From  photograph  taken  during  life.     (Osier.)  ] 


seen  so  many  errors  arise  from  the  use  of  carbonic-acid  gas  that  I 
consider  the  latter  only  a  poor  compromise.  I  shall  cite  but  one 
of  many  examples  of  this :  A  colleague  failed  to  recognize  a 
marked  dilatation,  which  extended  to  midway  between  the  um- 
bilicus and  the  symphysis,  in  spite  of  his  having  given  a  Seidlitz 
powder  to  the  patient,  because  the  quantity  of  gas  evolved  was 
actually  insufficient  for  the  capacity  of  the  stomach.*  The  percus- 
sion note  over  the  inflated  stomach  is  always  tympanitic  and  more 

*  [Nevertheless,  Osier,  Riegel,  and  many  other  good  observers  express  them- 
selves as  being  satisfied  with  the  carbonic-acid  gas  method.  It  possesses  the  very 
great  advantage  over  the  inflation  with  air  that  the  introduction  of  the  stomach  tube 
is  unnecessary.  A  teaspoonful  of  sodium  bicarbonate  and  not  quite  a  teaspoonful 
of  tartaric  acid,  or  the  two  powders  of  a  Seidlitz  powder,  are  each  dissolved  in  half 


DIAGNOSIS   OF   GASTRECTASIS.  259 

or  less  high  according  to  the  contents  and  the  tension  of  its  walls. 
Should  the  transverse  colon  be  markedly  distended  and  the  curva- 
ture of  the  stomach  lie  immediately  next  it,  it  may  at  times  emit 
the  same  note,  and  thus  render  it  an  impossibility  to  define  the 
boundary  between  the  two  organs  by  means  of  percussion.  In 
such  a  case  we  must  either  fill  the  stomach  with  fluid,  and  then 
percuss  in  order  to  contrast  its  dullness  with  the  tympanites  of  the 
colon ;  or  we  must  force  more  air  into  the  latter  from  the  rectum, 
thereby  producing  either  a  change  in  position  or  a  higher  tympa- 
nitic note.  Here  it  is  well  to  remember  that  delicate  diflferences 
in  sound  frequently  become  more  distinct  by  the  use  of  auscul- 
tatory percussion  when  the  ordinary  method  of  percussion  with 
the  pleximeter  leaves  us  in  the  lurch,  and  that  therefore  this 
method  can  also  be  utilized  in  doubtful  cases.  Ferber*  has  called 
attention  to  the  fact  that  the  circular,  tympanitic  "  stomach-lung 
region  "  {Magen-Lungenraum)  formed  by  the  stomach  under  the 
lower  lobe  of  the  left  lung  gradually  disappears  behind  the  axillary 
line  if  the  organ  be  normal,  while  if  it  be  dilated  it  may  be  traced 
to  the  vertebral  column.  Kernig  lays  stress  upon  the  fact  that  on 
examination  in  the  recumbent  posture  of  patients  with  dilated 
stomachs  the  dullness  in  the  left  lateral  region  disappears  on  turn- 
ing over  on  the  right  side,  a  tympanitic  note  appearing  instead. 
This  does  not  occur  in  normal  subjects ;  on  the  contrary,  the  dull- 
ness either  persists,  or  is  displaced  a  little  laterally  forward,  or 
gives  a  little  less  dull  note  than  when  recumbent.  The  same  is 
true  if  the  percussion  is  done  while  standing.  Yet  it  is  evident, 
a  priori,  that  this  must  depend  essentially  upon  the  quantity  of  gas 
and  ingesta  in  the  stomach  and  intestines ;  for  Kernig  also  found 
differences  even  in  healthy  persons  according  to  the  length  of  time 
which  had  elapsed  since  taking  food,  so  that  there  was  no  distinct 
dullness  in  the  third  to  the  fifth  hour  after  a  meal. 

On   the   other   hand,  I   have   repeatedly  found  that  when  the 
dilatation  is  well  marked  the   differences  in  dullness   on   postural 

a  goblet  of  water  and  drunk  in  rapid  succession.  The  patient  must  refrain  from 
belching.     If  in  doubt,  we  can  always  resort  to  inflation  with  air. — Ed.] 

*  Perber.     Ein  Beitrag  zur  Magenpercussion,  etc.    Deutsche  Zeitschr.  f.  prakt. 
Med.,  1876,  No.  42. 


260  DISEASES   OF   THE  STOMACH. 

changes,  as  above  described,  persisted  in  all  stages  of  digestion  and 
even  when  fasting. 

Dehid's  Tnethod^  has  been  recommended  for  determining  the 
boundaries  of  the  stomach  in  normal  and  pathological  conditions. 
On  an  empty  stomach  the  patient  drinks  a  litre  [quart]  of  water 
interruptedly  in  four  portions  of  ^  litre  [  ^  viij]  each.  If,  now, 
after  every  J  litre  we  percuss  out  the  resultant  lower  crescentic 
limit  of  dullness  against  the  tympanitic  transverse  colon,  we  find  in 
a  healthy  person,  while  erect,  that  the  stomach  moves  downward 
according  to  the  greater  amount  of  fluid  it  contains,  but  that  it 
never  extends  beyond  the  umbilicus  as  a  rule,  coming  only  to 
within  a  few  centimetres  [an  inch]  of  the  same.  In  the  recumbent 
posture  we  get  a  tympanitic  note  due  to  the  air  swallowed  with  the 
water,  and  this  prompt  change  of  the  percussion  note  is  a  strong 
proof  that  we  are  dealing  with  the  stomach  and  not  perchance 
with  the  intestine.  I  have  found,  however,  that  the  latter  is  not 
true  in  all  cases,  for  if  the  transverse  colon  is  markedly  dilated 
and  contains  watery  stools,  the  same  difference  in  resonance  will 
be  observed.  Yet  this  will  cause  confusion  in  only  a  few  excep- 
tional cases. 

At  the  same  time,  this  procedure  allows  us  to  recognize  the  con- 
ditions of  motor  insufficiency  or  atony  of  the  stomach — i.  e.,  its 
temporary  dilatation  and  its  persistent  ectasis — ^which  so  often  is  the 
immediate  result  of  the  former ;  for  it  is  evident  that  the  more  re- 
laxed the  gastric  walls  are,  the  sooner  will  the  lower  boundary  of 
the  stomach  reach  its  most  dependent  position  even  after  the  intro- 
duction of  small  quantities  of  fluid,  or  in  cases  of  marked  di^latation 
it  will  be  found  in  an  abnormally  low  position  at  the  very  com- 
mencement. [In  other  words,  Dehio's  method  is  an  excellent 
means  of  determining  the  tone  or  contractility  of  the  gastric  mus- 
cular wall.]  The  conditions  which  must  exist  to  enable  us  to  use 
this  method  of  exploration  are,  of  course,  that  the  intestines,  and 
especially  the  transverse  colon,  must  contain  air;  that  there  is  no 
abnormal  configuration  of  the  stomach ;  and,  finally,  that  the  ab- 


*  Dehio.     Zur   physikalischen    Diagnostik   der   meehanischen   Insufficienz   des 
Magens.    Verhandl.  des  vii.  Congresses  f.  innere  Mediein,  1888. 


DIAGNOSIS  OP  aASTRECTASIS.  261 

dominal  walls  are  not  so  thick  as  to  entirely  prevent  the  transmis- 
sion of  the  more  delicate  drfferences  in  sound. 

3.  Palpation. — Leube  has  recommended  "palpation  of  the  tip 
of  the  tube  "  in  order  to  recognize  dilatation  of  the  stomach.  A 
stiff  sound  is  introduced  into  the  stomach  until  it  meets  with  re- 
sistance, as  far  as  this  is  feasible  without  the  employment  of  undue 
force.  If,  now,  the  point  of  the  sound  can  be  palpated  below  the 
level  of  the  umbilicus,  dilatation  of  the  stomach  is  proved  to  exist. 
It  seems  that  Leube  himself  does  not  value  this  method  very 
highly ;  furthermore,  it  has  not  become  popular  on  account  of  the 
inconveniences  connected  with  it  and  because  the  results  are  doubt- 
ful. Albutt  *  is  right  in  saying :  "  In  my  opinion  palpation  of  the 
tip  of  the  sound  is  unnecessary  when  the  abdominal  walls  are  thin, 
while  in  stout  persons  the  instrument  can  not  be  distinctly  felt." 

[Boas  f  has  recently  called  attention  to  this  method  and  claims 
excellent  results  from  it.  A  very  long,  soft-rubber  tube  is  intro- 
duced into  the  stomach,  and  if  the  abdominal  walls  are  sufficiently 
relaxed  the  tube  may  readily  be  palpated  along  the  greater  curvature. 
Experiments  made  by  Schmilinsky  %  show  that  the  tube  invariably 
passes  on  until  it  reaches  the  greater  curvature  and  then  glides 
along  it  until  it  reaches  the  pylorus.  According  to  him,  Fig.  3 
(page  16)  is  incorrect.  It  is  to  be  noted  that  not  the  tip,  but  the 
tube  itself,  is  palpated.  If  any  doubt  exists  as  to  what  is  palpated, 
the  tube  may  be  withdrawn ;  while  this  is  being  done  we  may 
readily  feel  the  tube  slip  from  under  the  fingers.  To  avoid  errors, 
the  epigastrium  ought  to  be  palpated  before  the  introduction  of  the 
tube.  The  examination  is  made  either  on  an  empty  stomach  or 
after  introducing  one  to  two  pints  of  water.  It  is  best  done  in  the 
recumbent  posture.  The  instrument  moves  with  respiration,  and 
the  position  of  the  pylorus  may  also  be  ascertained.  The  method 
will  not  be  successful  in  fat  people  or  patients  with  rigid  abdo- 
mens. 

With  a  Httle  practice  the  method  is  easily  learned.     Boas  was 

*  Loc.  cit. 

t  [Boas,  Centralblatt  fiir  innere  Med.,  February  8,  1896.— Ed.] 
X  [Schmilinsky,  Ueber  Sondenpalption  und  die  Lage  des  Magens.    Boas's  Arehiv, 
Bd.  ii,  p.  215.— Ed,] 


262  DISEASES  OP  THE  STOMACH. 

successful  in  25  out  of  30  cases ;  Schmilinsky  failed  to  feel  tlie 
sound  in  only  3  out  of  100  cases.  My  experience  witli  the  method 
is  at  present  rather  limited ;  but,  so  far  as  I  can  now  express  an 
opinion,  I  would  say  that  it  promises  to  be  a  very  useful  procedure. 

Osier  *  calls  attention  to  the  fact  that  palpation  will  often  en- 
able us  to  recognize  the  position  of  the  pylorus  by  noting  that  in 
following  the  peristaltic  waves  the  muscular  contractions  at  the 
pylorus  are  unusually  firm ;  in  some  instances  the  contractions  and^ 
relaxations  remind  one  of  the  uterus.  Furthermore,  in  palpating 
the  pylorus  region  gas  may  be  felt  as  it  gurgles  through  the  pylorus. 
This  is  usually  marked  when  the  stomach  is  inflated ;  but  it  may 
also  occur  spontaneously  and  at  regular  intervals.  "In  doubtful 
tumors  of  this  region  this  is  a  sign  to  which  scarcely  suflacient  atten- 
tion has  been  paid." 

Another  point  to  which  Osier  directs  attention  is  that  in  dila- 
tation of  the  stomach  the  palpation  of  a  pyloric  tumor  may  be  very 
variable  from  time  to  time,  according  to  the  degree  of  distention  of 
the  stomach.     See  Figs.  6  and  13  {loc.  C'/z5.).] 

4.  Auscultation. — If  we  place  our  hands  flat  on  the  region  of 
the  stomach  and  give  the  abdominal  walls  a  series  of  rapid  consecu- 
tive shocks,  or  if  we  shake  the  body  in  toto,  we  can  hear,  either  at  a 
distance  or  with  the  stethoscope,  sounds  of  a  splashing  character 
with  a  faint  metallic  timbre,  the  so-called  succussion  or  splashing 
sounds,  the  clapotement  of  the  French.f  [Succussion  sound  can  ■ 
usually  be  brought  out  best  by  striking  the  abdomen  with  the  ulnar 
side  of  the  hand,  care  being  taken  that  the  abdominal  parietes  are 
relaxed  as  much  as  possible.  By  successively  striking  the  abdomen 
from  above  downward,  and  noting  where  the  sounds  cease  or 
change  in  character,  we  are  often  enabled  to  at  once  determine  the 
solution  of  the  lower  curvature.  The  patient  must  be  in  the  recum- 
bent posture.]  In  themselves  they  have  no  pathognomonic  signifi- 
cance.    They  may  arise  in  the  transverse  colon  as  well  as  in  the 

*  [Osier,  loc.  cit,  p.  26.— Ed.] 

f  Audhui.  Du  bruit  de  flot  ou  de  clapotage  de  I'estomac  comme  sigue  de  dila- 
tation de  restomae.  Gaz.  des  hopit.,  1883,  No.  47. — Girandeau.  De  la  dilatation 
de  Testomac.  Arch,  general,  de  med.,  1885,  p.  342.  Duplay,  in  1833,  was  the  first 
to  direct  attention  to  this  in  France.  [Rose,  N.  Y.  Medical  Journal,  June  15,  1895, 
p.  739.— Ed.] 


DIAGNOSIS  OF  GASTRECTASIS.  263 

stomaeli,  and  are  frequently  lieard  under  perfectly  normal  circum- 
stances immediately  after  the  ingestion  of  a  large  quantity  of  fluid, 
wlien  tliey  can  readily  be  produced  by  short  and  energetic  contrac- 
tions of  the  abdominal  muscles.     They  only  become  pathognomonic 

(1)  when  they  are  present  some  time  after  fluid  has  been  taken,  and 

(2)  when  they  are  positively  produced  in  the  stomach.  At  times 
the  latter  can  only  be  determined  by  completely  emptying  (siphon- 
ing out)  the  stomach.  If,  then,  the  succussion  sounds  persist,  they 
are  to  be  referred  to  the  intestines.  These  conditions  are  frequently 
disregarded,  and  a  diagnosis  of  dilatation  of  the  stomach  is  rashly 
made.  In  this  way  only  can  we  explain  the  fact  that  certain 
French  authors  (Bouchard  and  others)  find  dilatation  of  the  stom- 
ach not  only  in  every  dyspeptic,  But  that  Bouchard  finds  it  present 
in  about  30  per  cent  of  all  sick  people.  This  is  an  exaggeration 
which  is  not  shared  by  sober-minded  observers  like  Germain  See 
and  Dujardin-Beaumetz. 

[Bianchi's  phonendoscope  *  promises  to  be  a  very  useful  instru- 
ment in  auscultating  the  size  of  the  stomach.  The  method  of  using 
it  is  simple,  and  my  experience  with  it  has  been  very  satisfactory.] 

Pauli  was  the  first  after  Penzoldt  f  to  call  attention  to  a  sound 
in  the  stomach  like  escaping  vapor,  similar  to  that  made  by  uncork- 
ing a  bottle  of  Selters  water,  and  in  fact  this  can  occasionally  be 
recognized  on  auscultating  in  the  region  of  the  stomach  when 
marked  fermentative  processes  are  present.  Of  a  different  kind 
are  the  sounds  called  by  Kussmaul;]:  "cooing  or  clapping  sounds" 
{Gurr-  oder  Klatschgerausche),  which,  as  I  have  mentioned  above, 
may  be  produced  in  many  persons,  both  with  and  without  dilatation 
of  the  stomach,  by  the  active  contraction  of  the  abdominal  muscles 
or  by  rapidly  alternating  pressure  and  relaxation  on  the  passive  ab- 
dominal wall.  Unlike  the  succussion  sounds,  they  are  best  pro- 
duced in  the  erect  posture.  ' 

At  times  we  can  hear,  even  at  a  distance,  the  heart-sounds  re- 
sounding with  a  metallic  character  from  the  stomach  filled  with  air. 

*  [For  details  of  the  instrument  and  mode  of  employment,  see  Schwalbe,  Deutsch, 
med.  Wochensehr..  July  30,  1896.— Ed.1 

f  Penzoldt.     Die  Magenerweiterung.     Erlangen,  1877. 
X  Kussmaul,  in  Volkmann's  Samml.  klin.  Vortrage,  No.  181. 
18 


264  DISEASES  OP  THE  STOMACH. 

Striimpell  and  Laker*  sj)eak  of  sounds  wliicli  could  be  heard  at 
quite  a  distance  and  wliicli  were  isochronous  with  respiration  in  a 
patient  with  dilatation  of  the  stomach.  I  have  made  similar  obser- 
yations,  but  they  are  simply  to  be  regarded  as  curiosities.  The  note 
produced  in  Stabchen-Plessimeter-Percussion  f  also  has  a  metallic 
character,  and  in  favorable  cases  can  even  be  used  to  define  the 
limits  of  the  organ  against  the  coils  of  intestine  (Leichtensteru). 

The  occurrence  of  the  deglutition  murmurs  can  not  be  utilized 
in  the  diagnosis  of  dilatation.  I  have  never  been  able  to  observe 
any  characteristic  change  in  them,  although  I  have  examined  every 
accessible  case  for  this  purpose. 

Rosenbach  :|:  has  suggested  a  method  which  is  based  upon  aus- 
cultation of  air  blown  throuo-h  a  tube  which  is  introduced  into  the 
stomach.  If  we  pour  water  into  a  healthy  stomach,  introduce  a 
tube  below  its  surface,  and  blow  in  air,  we  will  then  on  auscultation 
hear  large,  moist,  metallic  rales,  which  disappear  when  the  tube  is 
slowly  withdrawn  as  soon  as  its  eye  is  above  the  level  of  the  fluid. 
Therefore  the  surface  of  the  fluid  is  assumed  to  be  at  the  spot 
where  the  rales  cease  to  be  heard.  If,  after  having  thus  determined 
this  point,  we  pour  an  additional  quantity  of  water,  say  one  litre 
[quart],  into  a  healthy  stomach,  we  will  find  that  the  level  of  the 
fluid  has  become  appreciably  higher,  while  in  the  case  of  an  exist- 
ing dilatation  very  little  displacement  is  said  to  occur.  In  practice 
this  method  is  quite  difficult  to  carry  out,  and  may  be  placed  on  a 
plane  with  Leube's  palpation  of  the  sound,  inasmuch  as  it  is  un- 
necessary for  the  recognition  of  large  dilatations,  while  in  less 
marked  conditions  it  fails  of  its  purpose.  Furthermore,  the  method 
is  rendered  entirely  superfluous,  because  Dehio's  method  is  much 
simpler. 

5.  Mensuration  of  the  Stomach. — As  already  stated  on  page  92 
this  may  be  determined  either  by  ascertaining  the  volume  of  air 

*  Berl.  klin.  Woehenschr.,  1879,  No.  30.  Aus  den  Sitzungsberichten  der  med. 
Gesellschaft  zu  Leipzig. — Laker.  Ueber  ein  rhythrnisches  Klangphanomen  des 
Magens.     Wiener  med.  Presse,  1889,  Nos.  43  and  44. 

f  [This  is  a  form  of  auscultatory  percussion  in  which  the  percussion  note  is 
elicited  by  striking  a  pleximeter  with  some  hard  object,  as  a  lead  pencil,  handle  of 
percussion  hammer,  etc. — Ed.] 

X  Loc.  cit. 


DIAGNOSIS  OP  GASTRECTASIS.  265 

which  can  be  inflated  into  the  stomach,  or  by  measuring  the  amount 
of  water  which  is  required  to  fill  it.  For  this  purpose  the  stomach 
must  be  filled  as  full  as  possible  and  then  be  entirely  emptied ;  but 
when  is  it  full  ?  We  must  either  rely  on  the  statements  of  the 
patients,  who  generally  experience  a  distinct  sensation  when  the 
stomach  begins  to  be  more  markedly  filled,  or  we  must  wait  till 
they  vomit  the  superfluous  quantity  of  water.  Neither  sign  can  be 
absolutely  depended  upon,  since  the  point  in  question  varies  with 
the  sensitiveness  of  the  patient  and  the  tone  of  the  gastric  muscular 
fibers,  and  the  capacity  of  the  stomach  is  so  different  individually. 
Therefore  the  first  method  is  preferable  if  it  is  carefully  carried 
out.  That  the  results  are  variable  and  not  absolute  has  already 
been  shown  (page  92). 

Ost  *  has  called  attention  to  the  fact  that,  even  normally  a  por- 
tion of  the  inflated  air  seems  to  escape  into  the  intestines ;  for,  after 
inflation  and  then  emptying  the  stomach  of  its  air  as  far  as  possi- 
ble, Ost  regularly  found  that  the  circumference  of  the  abdomen 
had  increased  a  few  centimetres.  Kuttner  verified  this  statement 
by  experiments  at  the  Augusta  Hospital;  in  almost  every  instance 
the  circumference  of  the  abdomen  increased  1  to  2  centimetres  \_f  to 
f  inch].  That  gas  may  readily  escape  from  the  stomach  into  the 
intestines  had  been  shown  in  1888  by  Senn,f  in  his  experiments  on 
dogs  into  whose  stomachs  he  had  inflated  hydrogen. 

But  where  such  gross  errors  can  not  be  avoided,  it  is  futile  to 
calculate  the  expansion  of  the  air  in  the  stomach,  as  proposed  by 
Jaworski,  Ost,  and  Kelling. :{: 

But,  as  things  stand,  we  must  abstain  from  laying  undue  stress 
upon  small  differences  in  measuring  the  capacity  of  the  stomach,  and 
should  only  speak  positively  of  an  absolutely  large  stomach  when  its 
capacity  exceeds  1,500  to  1,600  c.  c.  [  ^  1  to  liij],  although  even  these 
figures  are  not  to  be  taken  absolutely,  but  only  as  approximate.* 

*  Ost.  Beitrage  zur  Bestimmung  der  Capacitat  des  Magens.  Inaug.  Dissert. 
Dorpat,  1891. 

t  Senn.  Inflation  of  the  Stomacti  with  Hydrogen  Gas.  Medical  News,  Aug. 
25,  1888. 

X  Kelling.  Ein  einfaches  Verfahren  zur  Bestimmung  der  Magengrosse  mittels 
Luft.     Deutsch.  med.  Wochenschr.,  1892,  Nos.  51-52. 

*  [A  very  careful  study  of  the  mensuration  and  situation  of  the  stomach,  intra- 


266  DISEASES  OP  THE  STOMACH. 

[The  use  of  the  gastrodiaphane  in  determining  the  size  of  the 
stomach  has  ah-eady  been  discussed  on  page  96,] 

Etiology  of  Dilatation  of  the  Stomach. — Dilatations  of  the  stomach 
are  produced  by  two  etiological  factors :  (1)  mechanical  stenoses  of 
the  pyloms,  (2)  absolute  or  relative  weakness  of  the  expulsive  forces 
— in  other  words,  atonic  conditions  of  the  muscularis.  It  is  self- 
evident  that  in  a  normally  acting  stomach  the  relations  between  con- 
tents, muscular  action,  and  resistance  at  the  pylorus  must  be  in  the 
proper  proportion ;  therefore  any  change  in  these  factors  must  lead 
to  a  disturbance  of  function,  which  in  most  cases  gives  rise  to  dilata- 
tion of  the  organ.  However,  the  requisite  relationship  may  be  pre- 
served by  compensation,  in  spite  of  abnormal  change  of  the  indi- 
vidual factors,  and  only  when  this  fails  do  we  get  functional  dis- 
turbance, just  as  in  cardiac  disease  there  is  no  circulatory  disturb- 
ance until  the  compensation  of  the  valvular  lesions,  etc.,  becomes 
inefficient.  Oser  *  has  already  made  use  of  this  explanation  as  the 
basis  of  his  discussion  of  gastric  dilatation,  and  it  will  also  be  suffi- 
cient for  us.  f  For  the  purposes  of  compensation  the  organism  has 
hypertrophy  of  the  muscularis  at  its  disposal ;  however,  it  is  to  be 
remembered  that  only  rarely  does  the  hypertrophy  of  the  muscular 
layer  manifest  itself  in  an  appreciable  thickening,  but  that  as  a  rule 
it  is  not  recognizable,  since  the  individual  fasciculi  are  separated  and 
at  the  same  time  spread  out  by  the  dilatation  of  the  organ.  How- 
ever, under  such  circumstances  if  it  were  possible  to  conceive  of  the 
stomach  being  reduced  to  its  normal  size,  the  amount  of  muscular 
tissue  remaining  the  same,  we  would  find  this  layer  quite  markedly 
increased  in  thickness. 

In  order  to  gain  a  satisfactory  insight  into  the  nature  of  dilata- 
tion of  the  stomach  we  must  above  all  recognize  the  fact  that  we 
have  always  to  deal  with  a  consecutive  process,  a  symptom,  but  not 

gastric  pressure,  etc.,  will  be  found  in  Kelling,  Volkmann's  Sammlung  klinische 
Vortrage,  No.  144,  Feb.,  1896.— Ed.] 

*  L.  Oser.  Die  Ursachen  der  Magenerweitemng.  Wiener  med.  Klinik,  1881, 
No.  1. 

t  [Oser  has  graphically  represented  this  relation  in  the  formula  C  >  I  +  W,  in 
which  C  =  contractility  of  the  stomach,  I  =  resistance  from  gastric  contents,  and 
W  =  resistance  at  pylorus.  The  results  of  disturbance  of  these  factors  in  causing 
dilatation  and  the  changes  which  are  necessary  to  maintain  the  normal  relations 
may  be  seen  at  a  glance. — Ed.] 


ETIOLOGY   OP  GASTRECTASIS.  267 

with  an  independent  disease,  and  that  therefore  the  most  varied 
causes  may  be  involved,  as  long  as  they  call  into  existence  the  pre- 
liminary conditions  soon  to  be  spoken  of.  To  be  sure,  the  clinical 
picture  of  dilatation  of  the  stomach,  when  it  is  fully  developed,  is 
very  uniform,  and  so  marked  when  contrasted  with  this  diversity 
of  the  etiological  factors,  that  as  a  rule  it  predominates  and  more  or 
less  relegates  the  original  trouble  to  the  background.  Yet,  for  this 
very  reason,  it  becomes  our  imperative  duty  to  seek  for  the  cause 
in  every  case  of  dilatation  of  the  stomach,  especially  since  by  its 
recognition  the  prognosis  is  by  no  means  immaterially  influenced. 
For,  accordino;  to  the  character  of  this  causative  factor  will  there  be 
a  transient  or  permanent  condition,  a  reparable  or  an  irreparable 
disturbance.  We  must  therefore  differentiate,  as  I  have  already 
mentioned  at  the  beginning  of  this  chapter,  between  functional  and 
organic  dilatations ;  i.  e.,  between  those  forms  of  dilatation  of  the 
stomach  which  do  not  result  in  a  material  lesion  of  the  motor  appa- 
ratus together  with  its  nerves — therefore  those  which  can  be  cured — 
and  those  in  which  the  circumstances  will  not  permit  such  a  result 
because  severe  degenerative  processes  have  developed  in  the  gas- 
tric wall.  But  at  times  the  functional  dilatations  may  even  arise 
acutely ;  at  any  rate,  they  are  always  of  relatively  short  duration, 
so  that  they  do  not  lead  at  all  to  the  classical  symptoms  of  dilatation 
of  the  stomach,  or  only  do  so  transiently ;  they  run  the  course 
rather  of  dyspeptic  conditions  peculiar  to  the  special  underlying 
disease  of  the  organ,  chronic  gastritis,  atony,  or  the  neuroses.  [Boas 
and  others  *  have  reported  cases  of  acute  dilatation  of  the  stomach. 
This  condition  may  arise  either  from  overloading  the  viscus, 
traumatisms,  or  from  central  or  peripheral  nervous  causes  (see  page 
2*30).  Rosenheim  +  also  states  that  he  has  observed  cases  in  which 
mechanical  insufficiency  of  the  stomach  occurred  periodically  in 
attacks.  The  patients  in  whom  he  observed  this  were  neuras- 
thenics.] 

But  it  is  important  not  to  confound  the  chnical  symptoms  of 
gastrectasis  with  the  anatomical  condition  of  the  organ;  for  the 

*  fBoas.  Deutsch.  med.  Woehenschr,,  1894,  pp.  155  and  172;  Rosenheim,  Magen- 
krankheiten.  2te  Aufl.,  p.  452. — Ed.] 
t  [Rosenheim,  loc.  cit.,  p.  453, — Ed.] 


2G8  DISEASES  OF   THE   STOMACH. 

clinical  picture  is  primarily  a  series  of  symptoms  caused  by  fer- 
mentation and  stagnation  of  the  cliyme  which  are  usually,  but  not 
9;lways,  due  to  a  dilated  stomach,  yet  which  may  arise  whenever 
stagnation  and  decomposition  of  the  stomach  contents  occur  from 
any  cause.  It  is  well,  therefore,  to  distinguish  dilatation  proper 
from  the  symptoms  of  gastric  fermentation,  which  may  at  times  be 
present  without  any  dilatation  whatsoever.  A  case  of  the  latter  I 
shall  describe  later  on. 

The  mechanical  factors  which  lead  to  the  stenosis  or  occlusion 
of  the  pylorus  are  situated  either  in  the  wall  of  the  stomach  itself 
or  extend  to  it  from  without.  Among  the  most  frequent  causes  of 
the  former  class  and  of  prime  importance  are  carcinoma  and  cica- 
tricial contraction,  whether  this  be  due  to  direct  cicatrization  of  an 
ulcer,  or  produced  by  inflammatory  processes  following  ulcer  or 
phlegmonous  gastritis.  Cicatrization  is  usually  due  to  ulcers  situ- 
ated near  the  pylorus,  the  healing  of  which  causes  not  alone  a  ste- 
nosis but  also  frequently  a  thickening  of  the  pylorus,  which  may  even 
be  palpated  through  the  abdominal  walls,  and  which  may  be  mis- 
taken for  a  malignant  neoplasm.  As  will  be  shown  later,  this  error 
may  be  avoided  by  the  examination  of  the  stomach  contents.  At 
all  events,  cicatrization  of  ulcers  is  a  quite  frequent  cause  of  dila- 
tation. Neoplasms  at  the  pylorus  usually  involve  the  greater  part 
of  its  circumference,  or  may  surround  it  entirely  like  a  ring ;  or 
they  may  be  situated  above  the  pylorus  and  have  warty  or  polypoid 
excrescences,  which  force  themselves  into  the  orifice  somewhat  like 
a  cork.  I  observed  such  a  condition  in  a  case  in  which  a  very  vas- 
cular polypoid  tumor,  larger  than  a  walnut,  was  situated  on  the  pos- 
terior wall  of  the  stomach,  its  base  being  about  3  centimetres  [1^ 
inch]  above  the  pylorus,  and  which  during  life  must  have  more  or 
less  completely  occluded  the  passage  like  a  ball  valve  according  to 
its  vascularity  ;  the  pylorus,  although  somewhat  narrowed,  would 
easily  admit  the  little  finger  (Fig.  36).  Bernabel  *  reports  a  similar 
case,  which  is  remarkable,  however,  by  the  formation  of  true  pe- 
dunculated polypi.     The  largest  was  6'8  centimetres  [2f  inches]  in 


*  Bernabel.     Contribnzione  al  etiologia  del  vomito  mecanico  da  polypo  gastrico. 
Rivist.  clin.  di  Bologna,  1882. 


ETIOLOGY  OF  GASTRECTASIS.  269 

length,  and  was  situated  on  the  anterior  wall  of  the  stomach,  5  centi- 
metres [2  inches]  above  the  pylorus. 

On  the  other  hand,  it  is  self-evident  that  all  stenoses  of  the  duo- 
denum, especially  of  its  superior  horizontal  portion,  must  also  cause 
dilatation  of  the  stomach.  In  Cruveilhier  ^  may  be  found  the  draw- 
ing of  a  tumor,  about  the  size  of  a  potato,  situated  in  the  duodenum 
immediately  below  the  pylorus,  which  must  have  had  the  same  effect 
as  a  true  pyloric  stenosis.  Unique  among  such  obstructions  is  the 
case  described  by  Pertik,f  in  which  a  diverticulum  shaped  like  a 
glove-finger  was  situated  in  the  duodenum  at  the  level  of  Yater's 
papilla,  which,  according  to  the  degree  to  which  it  was  filled  by  the 
chyme  coming  from  the  stomach,  must  have  prevented  its  passage 
through  the  duodenum.  Pertik  endeavors  to  explain  the  origin  of 
this  diverticulum  as  being  due  to  an  unusually  well  developed  fold 
of  mucous  membrane  which  was  gradually  made  larger  by  the  pres- 
sure of  the  chyme,  in  the  same  way  as  similar  semilunar,  diaphragm- 
like reduplications  of  mucous  membrane  hav^e  been  observed  by 
Deiters  ^  (Grawitz)  at  the  pylorus  and  also  in  other  parts  of  the 
small  intestines. 

Congenital  stenosis  of  the  pylorus  may  also  be  included  among 
the  mechanical  constrictions ;  such  cases  have  been  described  by 
Landerer,*  Maier,  ||  and  Hirschspring.^  There  may  be  either  a 
round  or  a  slit  like  contraction  of  the  ostium  pylori,  or  the  muscu- 
lar portion  of  the  pylorus  may  be  hypertrophied,  and  the  pyloric 
portion  of  the  stomach  present  a  spherical  or  conical  appearance,  in 
which  latter  case  it  projects  into  the  duodenum  Kke  the  cervix  uteri 
into  the  vagina.  This  hypertrophy,  by  the  way,  can  readily  be  dis- 
tinguished from  the  form  produced  by  chronic  catarrh  of  the  mu- 
cous membrane.     It  is  very  apparent  that  such  stenoses  may  cause 

*  Cruveilhier.     Anatomie  pathologique  du  corps  hiimain.     Livr.  4,  p.  1. 

f  0.  Pertik.  Beitrag  zur  Aetiologie  der  Magenerweiterung.  Virchow's  Arch., 
Bd.  114,  S.  437. 

:]:  Deiters.  Beitrage  zur  Aetiologie  der  Magenerweiterung.  Inaug.  Dissert, 
Greifswald,  1889. 

*  Ueber  angeborene  Stenose  des  Pylorus.     Inaug.  Diss.     Tiibingen,  1879. 

II  R.  Maier.  Beitrage  zur  angeborenen  Pylorus-stenose.  Virchow's  Arch.,  Bd. 
cii,  S.  413. 

^  Hirsehspring.  Falle  von  angeborencr  Pylorusstenose.  Jahrbiich.  f  iir  Kinder* 
heilkunde,  1888,  Heft  1. 


270 


DISEASES  OF  THE  STOMACH. 


F:a.  86.-yery  vaso.lar,  pol,po(d  tu.or,  on  posterior  wall  of  stomach,  U 


pylorus. 


inch  above  the 


ETIOLOGY   OF  GASTRECTASIS.  271 

the  development  of  a  dilatation  as  soon  as  tlie  expulsive  power  of 
the  pyloric  portion  of  the  stomach  is  unable  to  overcome  them 
— in  other  words,  as  soon  as  the  antrum  pylori  passes  from  the 
stage  of  hypertrophic  compensation  into  that  of  insufficiency.  When 
this  will  occur  depends  naturally  upon  individual  circumstances. 
While  in  these  cases  the  obstruction  to  the  emptying  of  the  stomach 
is  manifest,  in  other  cases  we  iind  the  pylorus  patent  after  death, 
and  yet  have  dilatation  of  the  stomach,  for  which  the  factors  of  ab- 
solute or  relative  muscular  insufficiency,  soon  to  be  discussed,  can 
either  not  be  applied  or  are  not  sufficient  to  account  for  it. 

Kussmaul  *  has  shown  by  experiments  on  the  cadaver  that  with 
great  relaxation  of  the  abdominal  walls  the  pylorus  may  assume  a 
vertical  position  due  to  the  rotation  of  the  full  stomach,  and  at  the 
same  time  so  twist  and  compress  the  horizontal  portion  of  the  duo- 
denum at  its  junction  with  the  stomach  that  not  a  drop  of  fluid 
can  escape  into  the  duodenum.  As  can  readily  be  understood,  the 
lumen  of  the  intestine  may  be  occluded  by  bending,  not  at  the  py- 
lorus, but  somewhat  below  it,  where  the  horizontal  curves  into  the 
descending  portion  ;  this  takes  place  when  the  stomach  is  filled  and 
its  ligaments  are  relaxed,  so  that  it  drags  the  horizontal  portion  of 
the  duodenum  down  with  it.  If,  m  addition,  there  exists  a  constrict- 
ing stenosis  of  the  pylorus,  then  dilatations  of  the  duodenum,  in  the 
form  of  ampullae,  may  be  added  to  the  dilatation  of  the  stomach,  as 
is  typically  depicted  in  the  accompanying  drawing,  taken  from  a 
paper  by  Cahn,f  which  at  the  same  time  gives  a  good  idea  of  the 
position  of  the  stomach  in  marked  dilatation  (Fig,  37). 

An  additional  factor  may  perhaps  be  found  in  the  following : 
While  under  the  usual  circumstances  the  demarcation  of  the  pylo- 
rus from  the  duodenum  consists  only  in  a  slight  constriction  or  in- 
chne,  but  passes  perfectly  smoothly  on  to  the  stomach,  we  occasion- 
ally find  an  actual  ring,  so  that  on  section  of  the  stomach  the  pylorus 
looks  as  though  a  cord  had  been  drawn  underneath  the  mucous 
membrane.  A  small  pouch  is  consequently  formed  on  the  gastric 
side  of  the  orifice,  which  may  easily  become  dilated  from  the  pres- 

*  Loc.  cit. 

t  Cahn.  Ueber  antiperistaltische  Magenbewegungen.  Deutsch.  Arch.  f.  klin. 
Med.,  Bd.  xsxv,  S.  414. 


272  DISEASES  OF  THE  STOMACH, 

sure  of  food,  and  thus  gradually  lead  to  a  true  dilatation.  I^Teces- 
sarily,  an  uncommonly  firm  closure  of  the  pylorus  would  be  requi- 
site for  this  to  occur — i.  e.,  a  spasmodic  contraction. 


Fig.  37. — Cancer  of  pylorus,  with  dilatation  of  stomach  and  duodenum.  Distance  of  the 
greater  curvature  from  the  symphysis  =  4  ctm.  [If  inch].  Portion  of  the  oesophagus 
in  the  abdominal  cavity  =  4  ctm.  [If  inch].  Length  of  lesser  curvature  =  10  ctm.  [4 
inches],  c  ~  carcinoma,  p  =  pancreas  ;  it  has  sunk  behind  the  lesser  omentum  to  the 
level  of  the  second  lumbar  vertebra,  d  =  horizontal  portion  of  the  duodenum ;  its  ver- 
tical portion  descends  to  the  pelvic  brim. 


ETIOLOGY  OF  GASTRECTASIS.  273 

Finally,  spastic  coni^action  of  the  pylorus  \^pylorospasm\  may 
cause  dilatation.  Such  a  condition  was  very  obvious  in  the  case  on 
which  Sanctuary  *  performed  an  autopsy.  The  pylorus  was  quite 
patent,  but  above  it  lay  an  egg-shaped  ulcer,  surrounded  by  normal 
mucous  membrane,  2|  inches  long  and  1  inch  wide,  the  irritation  of 
which,  from  the  movements  of  the  food,  evidently  produced  a 
marked  spastic  contraction  of  the  entire  pyloric  region.  A  pro- 
nounced dilatation  of  the  stomach  had  been  diagnosticated  during 
life.  However,  of  all  the  causes  which  have  been  brought  forward 
to  account  for  dilatation,  where  there  is  no  tangible  narrowing  of 
the  pylorus,  spastic  contraction  appears  to  me  to  be  the  most  doubt- 
ful ;  for  it  lies  in  the  very  nature  of  spastic  contractions  that  they 
do  not  persist  continually,  but  relax  at  times — consequently,  that 
they  can  not  produce  any  lasting  obstruction.  According  to  our 
present  experiences,  which  appear  to  be  pretty  generally  recognized, 
spasm  of  the  pylorus  is  produced  by  excessive  acidity  of  the  stom- 
ach contents  ;  according  to  this,  all  cases  of  hyperacidity  would 
finally  have  to  lead  to  dilatation  of  the  stomach,  which,  at  least  as 
far  as  our  present  knowledge  goes,  is  surely  not  the  case.f  It  is  at 
all  events  true  that  many  cases  of  gastrectasis  without  mechanical 
obstruction  are  accompanied  by  excessive  and  untimely  secretion 
of  HCl,  yet  it  remains  doubtful  whether  a  spasm  of  the  pylorus 
or  an  overloading  of  the  stomach  as  the  result  of  incomplete  diges- 
tion of  carbohydrates  is  the  exciting  cause.  A  well-observed  case 
of  this,  with  reference  to  the  final  result,  is  that  reported  by 
ISTauwerk  :  % 

A  woman,  twenty-three  years  old,  had  suffered  for  ten  months  with 
slight  dyspeptic  manifestations.  After  swallowing-  some  cherry  pits 
symptoms  of  closure  of  the  pylorus  suddenly  appeared,  continuous, 
obstinate  vomiting,  and  absolute  constipation.  Death  followed  three 
months  later.  The  muscular  layer  at  the  pylorus  was  found  to  be  7 
millimetres  [J  inch]  thick,  the  mucosa  4  to  5  millimetres  [^  inch],  the 
serosa  2  millimetres  [  y^^inch],  the  pyloric  orifice  being  quite  patent.     No 

*  Sanctuary.  Notes  of  Cases  of  Dilated  Stomach,  with  Remarks.  British  Med. 
Journal,  1883,  p.  618. 

f  [Fleiner  (Boas's  Arch.,  Bd.  i,  Heft  4)  believes  that  spasm  of  the  pylorus  occurs 
frequently  in  the  hyperacidity  which  accompanies  ulcer  of  the  stomach,  and  may 
even  explain  the  frequency  with  which  ulcers  occur  near  the  pylorus. — Ed.] 

X  Nauwerk.  Ein  Fall  hypertrophischer  Pylorusstenose  mit  hochgradiger  Ma- 
generweiterung.     Deutsch.  Arch.  f.  kliu.  Med.,  Bd.  xxi,  pp.  573-580. 


274  DISEASES   OF   THE   STOMACH. 

neoplasm  could  be  found  either  on  macroscopic  or  microscopic  examina- 
tion. There  were  ten  cherry  pits  still  present  in  the  enormously  dilated 
stomach. 

The  causes^  situated  external  to  the  stomachy  which  nfiay  lead  to 
stenosis  or  occlusion  of  the  pylorus,  are  either  tumors  which  exert 
pressure  upon  the  pyloric  orifice  (or  the  duodenum),  or  which  em- 
brace and  grow  around  it ;  such  neoplasms  arise  either  from  the 
pancreas,  the  omentum,  the  retroperitoneal  glands,  or  the  liver. 
Minkowski  *  reports  a  rare  occurrence  of  this  kind,  in  which  he 
observed  a  hard  tumor  which  was  considered  a  cancer  of  the  pylcJ"- 
rus  during  life,  combined  with  dilatation  of  the  stomach,  but  which 
after  death  was  found  to  be  the  gall  bladder  entirely  filled  by  a 
large  calculus ;  this  compressed  the  pylorus  completely  and  led  to 
the  enormous  dilatation.  In  this  case  examination  for  hydrochloric 
acid  would  have  definitely  excluded  carcinoma,  even  though,  as  we 
shall  see  later,  this  is  not  positive  ;  at  any  rate,  it  is  at  times  abso- 
lutely impossible  to  differentiate  between  tumors  of  the  liver  or 
gall  bladder,  or  biliary  calculi  and  neoplasms  of  the  stomach.  A 
number  of  cases  have  recently  been  published  f  in  which  gallstones 
were  either  wedged  in  the  orifice  of  the  common  duct  or  stenosed 
the  intestines  or  produced  fistulous  tracts  with  annular  cicatricial 
strictures ;  or  the  stones  had  perforated  the  intestines  directly  after 
adhesions  between  the  gall  bladder  and  the  intestines  had  been 
formed. 

Further,  if  an  old  peritonitis  gives  rise  to  cicatricial  bands  which 
surround  the  pylorus  or  force  it  toward  the  posterior  abdominal 
walls,  and  make  traction  upon  or  bend  the  pylorus — or  the  horizon- 
tal portion  of  the  duodenum — we  may  also  get  pyloric  stenosis. 
Rokitanski  :|:  has  seen  cases  of  gastrectasis  which  were  caused  by 

*  0.  Minkowski.  [Jeber  die  Gahrungen  im  Magen.  Mittheihmgen  aus  der 
med.  Klinik  zu  Konigsberg  in  Preussen,  p.  163. 

t  Grundzach.  Ueber  Gallensteine  ira  Magen.  Wiener  med.  Presse,  1891,  No.  28. 
— A.  Smith.  Some  Clinical  Points  on  Gastrectasia.  N.  Y.  Medical  Record,  February 
4.  1888.  [Bouveret  (Revue  de  Medecine,  January,  1896)  reports  additional  cases  of 
pyloric  stenosis  due  to  gallstones.  He  calls  attention  to  one  symptom  -which  is 
characteristic  of  stenosis  due  to  fixation  of  the  pylorus  by  adhesions — i.  e,,  the 
vomiting  and  other  symptoms  of  dilatation  persist  as  long  as  the  patient  is  active 
and  on  his  feet,  but  cease  as  soon  as  he  rests  in  the  recumbent  posture.  Abstracted 
in  Amer.  Journ.  Med.  Sciences,  June,  1896,  p.  738.— Ed.] 

X  Rokitanski.     Handbuch  der  pathol.  Anatomie,  Bd.  ii,  S,  178. 


ETIOLOGY   OP  GASTRECTASIS.  275 

large  scrotal  hernise  exerting  traction  upon  the  stomach  and  dislo- 
cating it  (and  possibly  also  bending  the  duodenum  ?).  Bartels  was 
the  first  to  call  attention  to  the  joint  occurrence  of  wandering  kid- 
ney on  the  right  side  and  dilatation  of  the  stomach,  accounting  for 
the  latter  by  the  pressure  made  by  the  kidney  upon  the  duodenum ; 
this  form  can  not  become  marked  unless  its  existence  dates  from 
childhood.  Malbranc  *  agrees  with  him,  and  Schiitz  f  reports  the 
case  of  a  woman  whose  diificulties  rapidly  disappeared  on  leaving 
off  her  corsets,  which  were  suj)posed  to  have  exerted  pressure  on 
the  dislocated  kidney.  Furthermore,  Litten  has  called  special  atten- 
tion to  the  connection  between  diseases  of  the  stomach  and  change 
in  position  of  the  right  kidney,:]:  and  has  seen  displacement  of  the 
right  kidney  and  dilatation  of  the  stomach  occurring  together  in  no 
less  than  55  per  cent  of  his  cases.  This  proportion  may  seem  rather 
high,  yet  according  to  Kuttner's  researches  *  it  can  not  be  much 
abo\'e  the  correct  figure.  But  a  floating  kidney  is  by  no  means  an 
indispensable  feature  in  every  dilatation  of  the  stomach,  since  Len- 
hartz  I  was  unable  to  find  a  floating  kidney  in  any  of  the  16  cases 
of  dilatation  which  he  examined  for  this  purpose.  Therefore  I 
agree  with  Oser,  J^othnagel,  and  Leube,"^  and  wish  to  emphasize 
the  fact  that  no  causal  relation  exists  in  the  majority  of  cases,  but 
that  it  is  a  simple  coincidence,  and  that,  as  has  been  conclusively 
shown  by  Kuttner,  in  many  cases  of  so-called  dilatation  with  float- 
ing kidney  there  is  no  gastrectasis,  but  either  a  megalogastria  or  a 
gastroptosis  which  has  deceived  inexperienced  observers.  At  all 
events,  Bartel's  views  are  untenable,  because  any  pressure  which  the 
right  kidney  might  exert  on  the  duodenum  necessarily  requires  that 
this  kidney  be  fixed  ;  but  its  characteristic  is  just  its  mobility ;  hence 
it  slips  away,  and  it  is  only  necessary  to  have  seen  in  an  animal  how 
energetically  the  intestinal  contents  are  forced  on  to  appreciate  how 

*  Malbranc.     Ein  complicirter  Pall  von  Magenerweiterung.     Berl.  klin.  Woch- 
enschr.,  1880,  No.  28. 

+  E.  Schiitz.     Wanderniere  und  Magenerweiterung.     Prager  medicin.  Wochen- 
schr.,  1885,  January  14th. 

t  Verhandlungen  des  Congresses  fiir  innere  Medicin.     Wiesbaden,  1887,  S.  223. 

*  Kuttner.     Ueber  palpable  Nieren.     Berl.  klin.  Wochenschr..  1890. 

II  Lenhartz.    Beitrage  zur  moderne  Diagnostik  der  Magenkrankheiten.    Deutsch. 
med.  Wochenschr..  1890,  No.  7. 
^  Log.  cit,  S.  225. 


276  DISEASES  OP  THE  STOMACH. 

easily  sucli  an  obstruction  could  be  overcome.  I  think  Landau* 
is  right  when  he  says  that,  even  for  physical  reasons,  the  kidney 
would  be  unable  to  exert  the  necessary  j)ressure  on  the  gut. 

The  second  great  group  of  dilatations  of  the  stomach  arises 
from  weakness  of  the  gastric  muscle^  and  differs  from  that  first 
spoken  of  in  that,  as  a  rule,  the  stomach  is  dilated  only  to  a  slight 
degree,  while  the  hypertrophy  of  the  muscularis  is  absent.  I  shall 
describe  these  conditions  as  atonic  gastric  dilatations  caused  by 
asthenia  or  ahinesis  [a,  without,  Kivico,  I  moveW  of  the  stomach. 
Predisposing  factors  are : 

1.  Wealcening  of  the  musctdar  tone,  due  either  to  excessive  de- 
mands (perhaps  traumatisms  ? )  upon  the  muscle  and  its  gradual 
relaxation,  or  to  insufficient  nourishment  of  the  contractile  elements 
of  the  gastric  wall  in  ansemia,  chlorosis,  nervous  affections,  acute 
and  chronic  diseases  of  an  exhausting  nature,  peritonitis,  amyloid 
degeneration  of  the  vessels.  Thus  we  find  that  chronic  gastric 
catarrh  must  also  be  included  among  the  etiological  factors  of 
dilatation  of  the  stomach.  Since  the  catarrhal  condition  causes 
the  ingesta  to  remain  for  a  longer  time  than  normal  in  the  stom- 
ach, it  is  overburdened,  and  a  relaxation  of  the  muscle  is  pro- 
duced, which,  as  we  shall  see  when  speaking  of  atrophy  of  the 
stomach,  finally  leads  to  separation  of  the  fibers  of  the  submucosa 
and  muscularis ;  dilatation  of  the  organ  is  the  result,  just  as  the 
bladder,  when  affected  with  catarrh,  finally  becomes  the  seat  of 
paralytic  dilatation.  It  is  in  this  sense  that  we  must  understand 
Clozier  %  when  he  includes  deficient  hygiene  in  combination  with 
continual  erect  position  of  the  body  among  the  causes  of  dilatation 
of  the  stomach.  But  some  writers  believe  that  dilatation  is  not 
caused  alone  by  the  chemical  insufficiency  which  is  associated  with 
gastric  catarrh,  but  also,  on  the  contrary,  by  the  excess  of  function, 


*  Landau.     Die  Wanderniere  der  Frauen.     Berlin,  1881,  S.  44. 

f  The  ancients  called  conditions  of  this  kind  frigiditas  stomacld.  Todd  wais 
probably  the  first  to  use  the  term  atony ;  Andral  introduced  the  phrase  dyspepsie 
par  asthenie  de  Vestomac ;  Broussais  designated  it  dyspepsie  asthenique.  The  most 
varied  dyspeptic  conditions  were  included  under  this  term. 

X  Clozier.  De  la  dilatation  dite  primitive  de  I'estomae.  Bull,  med.,  1888.  p. 
1245. 


ETIOLOGY   OP   GASTRECTASIS.  277 

hyperclilorhydria,  and  hypersecretion,  which  delays  the  digestion  of 
the  starches,  the  stomach  being  emptied  eitlier  not  at  all  or  only 
very  late. 

The  weakening  of  the  walls  of  the  stomach  is  not  only  brought 
about  by  overloading  the  stomach  with  improper  quantities  of  solid 
masses,  with  which  the  muscle  is  unable  to  cope,  but  also  by  the 
abnormal  production  of  gases  in  the  stomach,  together  with  closure 
of  the  orifices ;  the  latter  may  be  of  a  mechanical  nature  from  the 
commencement,  and  due  to  one  of  the  aforementioned  factors,  or 
may  be  due  to  the  occurrence  of  an  abnormal  fermentation  of  the 
ingesta,  which  only  leads  secondarily  to  muscular  insufficiency.  As 
we  know  best  from  our  observations  upon  the  intestines,  the  prod- 
ucts of  fermentation,  when  absorbed,  cause  an  irritation  of  the  mus- 
cle, which,  as  long  as  the  contractility  is  intact,  probably  leads  also 
to  the  simultaneous  closure  of  the  sphincters,  and  in  this  way  causes 
an  abnormally  long  detention  of  the  fermenting  masses  in  the  stom- 
ach. Later,  owing  partly  to  mechanical  distention,  partly  to  the 
venous  stasis  intimately  connected  therewith,  structural  changes  are 
jDroduced  in  the  mucosa  and  muscularis ;  also  paresis  and  degenera- 
tion, and  thus,  finally,  muscular  insufficiency  of  the  organ.  Thus  it 
is  that  we  find  dilatation  of  the  stomach  so  frequently  in  gluttons, 
diabetics,  insane  patients  with  polyphagia,  etc. ;  it  may  also  develop 
from  chronic  gastric  catarrh,  or  (probably  most  frequently)  it  may 
arise  from  a  combination  of  both  causes.  It  is  especially  due  to 
l^aunyn,*  and  his  pupil  Minkowski,f  that  these  processes  have  been 
properly  considered. 

2.  Weahness  and  paralysis  of  the  motor  nerve-fibers  of  the 
stomachy  or  diminished  excitability  of  the  nervous  apparatus  pre- 
siding over  peristalsis,  may  be  caused  by  local  lesions,  such  as  de- 
struction by  ulceration  of  the  branches  of  the  vagus  entering  the 
stomach  (Traube),  or  by  processes  of  inhibition  arising  from  other 
portions  of  the  nervous  system — for  instance,  the  paralyzing  infiu- 
ence  exerted  by  chronic  peritoneal  exudations  (Bamberger),  or  even 
by  a  simple  catarrh  of  the  stomach,  just  as  paralyses  of  the  muscles 

*  B.  Naimyn.     Ueber  das  Verhaltniss  der  Magengahrung  zur  mechan.  Magen- 
insufficienz.     Deutsch.  Arch,  f  iir  klin.  Med.,  Bd.  xxxi,  S.  225. 
f  Minkowski,  loc.  ait. 


278  DISEASES  OP  THE  STOMACH. 

of  the  vocal  cords  are  produced  by  laryngeal  catarrh.  To  this  is 
also  due  the  occurrence  of  dilatation  in  general  neuroses  and  gas- 
troptosis  and  enteroptosis,  conditions  which  will  be  described  later 
on.  Perhaps  it  is  here  that  we  must  include  those  rare  cases  of 
atonic  dilatation  of  the  stomach  which,  quite  contrary  to  the  ordi- 
nary course  of  events,  develop  as  the  result  of  chronic  obstinate 
constipation,  when,  as  a  rule,  just  the  opposite  occurs.  We  know 
that  there  is  no  sharp  line  of  demarcation  between  the  peristalsis 
of  the  intestines  and  that  of  the  stomach,  but  that,  rather,  the  peri- 
stalsis of  the  upper  portion  of  the  intestines  can  be  obhterated  by 
the  contractions  of  the  stomach,  as  Braam-Houckgeest  *  has  shown. 
On  the  contrary,  persistent  sluggishness  or  paresis  of  the  intestines 
may  give  rise  to  diminished  peristalsis  in  the  stomach.  G.  See  and 
Mathieu  f  have  also  called  attention  to  this  point.  I  saw  a  very 
striking  example  of  this  in  a  lady  thirty  years  of  age,  who  had  suf- 
fered with  obstinate  constipation  since  childhood  (the  trouble,  as  is 
not  at  all  infrequent,  was  hereditary  in  her  family),  and  who,  in  the 
course  of  my  observations,  extending  over  a  period  of  two  years, 
although  she  had  never  before  complained  of  stomach  trouble,  ac- 
quired a  typical  dilatation  of  the  stomach,  without,  it  is  true,  any 
marked  signs  of  decomposition,  but  yet  without  any  other  referable 
cause. 

3.  Finally,  the  expulsive  powers  may  be  weakened  by  the  ex- 
clusioii  of  a  more  or  less  sharply  defined  jportAon  of  the  muscular 
fibers  of  the  stomach.  Circumscribed  cancerous  infiltration  and 
ulcerations  which  do  not  stenose  the  stomach  but  destroy  a  portion 
of  its  muscle,  result  at  times,  if  their  growth  be  slow  enough,  in 
hypertrophic  dilatation  of  the  stomach.  [Infiltration  of  the  muscu- 
lar layers  occurs  very  early  in  cancer  of  the  stomach,  long  before 
there  is  any  stenosis  of  the  pylorus.  This  early  weakening  of  the 
gastric  motility  in  cancer,  combined  with  the  absence  of  HCl,  ex- 
plains the  early  occurrence  of  lactic  acid  in  this  disease.]  A  simi- 
lar  condition   is    produced   when    broad    bands  of   the   muscular 


*  Ewald,  Klinik,  etc.     I.  Theil,  3te  Aufl.,  S.  193. 

f  G.  See  et  Mathieu.  De  la  dilatation  atonique  de  restomac.  Rev.  de  med., 
May  10  and  Sept.  10,  1884.  A.  Mathieu.  Les  phenomenes  nervo-moteurs  de  la 
dyspepsie  gastrique.     Graz.  d.  hopit.,  1888,  No,  47. 


PATHOLOGY  OP  GASTRECTASIS.  279 

layer  of  the  stomach  are  destroyed  by  inflammatory  or  ulcerative 
processes,  and  cause  partial  dilatation  behind  the  site  of  the  ob- 
struction or  complete  gastrectasis.  Yery  instructive  pictures  of 
this  process  may  be  seen  in  Cruveilhier's  celebrated  Atlas  of  Patho- 
logical Anatomy.* 

Pathology. — I  have  already  discussed  the  gross  anatomical 
changes,  the  variations  in  the  size  of  the  dilated  stomach,  and  the 
changes  in  the  position  of  the  neighboring  organs  produced  there- 
by. At  present  the  changes  in  the  individual  coats  of  the  stomach 
are  of  special  importance.  It  has  been  known  for  a  long  time  that 
the  muscularis  may  be  totally  or  partially  thickened,  or  apparently 
normal  or  thinned ;  a  distinction  has  thus  been  made  between  hy- 
pertrophic and  atrophic  forms.  Hypertrophy  of  the  muscularis 
preponderates  in  the  pyloric  region,  and  occurs  most  frequently 
with  cancerous  or  cicatricial  stricture  of  the  pyloras.  Whether  in 
such  cases  there  is  a  true  hypertrophy,  or  only  an  apparent  thicken- 
ing of  the  muscular  wall  of  the  stomach  on  account  of  infiltration 
with  cancerous  elements,  can  frequently  be  decided  only  by  care- 
ful microscopic  examination.  In  the  chronic  inflammatory  forms 
Lebertf  claims  to  have  found  an  increase  in  the  thickness  to  14 
millimetres  [-^  inch]  ;  generally  it  amoimts  to  5  to  6  millimetres  [1- 
inch],  which  is  quite  considerable.  This  he  regards  as  the  result  of 
a  chronic  hypertrophic  inflammation  of  the  muscularis.  There  can 
be  no  doubt  that  the  hypertrophic  form  may  gradually  pass  into 
the  atrophic.  The  former  occurs  more  frequently  in  youthful  in- 
dividuals, the  latter,  without  exception,  in  the  aged ;  so  that  in  the 
numerous  cases  of  dilatation  of  the  stomach  in  old  people  on  whom 
I  have  performed  autopsies  I  have  never  found  hypertrophy  of  the 
muscularis,  it  being  much  oftener,  in  fact  in  the  majority  of  cases, 
of  normal  thickness  and  far  less  frequently  thinned.  The  individ- 
ual muscle  fibers  are  normal  in  appearance ;  the  nuclei  stain  well 
with  picro-carmine.  Since  18Y4  I  have  examined  a  large  number 
of  dilated  stomachs  microscopically,  but  I  have  never  found  hyper- 
trophy of  the  individual  muscle  cells  of  which  Lebert  speaks,  nor 
degeneration  of  these  cells  into  a  gelatinous  mass  (colloid  degenera- 

*  [Anatomie  pathologique  du  corps  humain.    Paris,  1830-1842,  2  vols. — Ed.] 
f  Lebert,  loc.  cit.,  pp.  535  et  seq, 
19 


280  DISEASES  OP  THE  STOMACH. 

tion),  as  described  by  Kussmaul  and  E.  Mejer,  and  also  found  by 
Cabn ;  frequently  there  existed  a  more  or  less  extensive  fatty 
degeneration.  Tbe  interspaces  between  the  individual  muscular 
fasciculi  appear  enlarged  and  traversed  by  strands  of  connective 
tissue.  Yery  often  an  infiltration  of  small  cells  is  present,  proceed- 
ing from  the  submucosa.  The  latter  forms  a  wide-meshed  tissue 
studded  with  numerous  round  cells  with  its  vessels  widely  dilated. 
The  mucous  membrane  presents  the  picture  of  chronic  gastritis 
in  its  different  stages.  In  the  glandular  cells  of  the  mucosa  there 
is  no  change  at  all  in  many  places ;  in  others  they  are  markedly 
cloudy  and  granular ;  in  still  others  they  show  cystic  degeneration, 
or  have  entirely  disappeared  in  a  round-celled  infiltration,  which 
also  fills  and  forces  the  meshes  of  the  interstitial  tissue  apart.  ]^o- 
where  can  we  recognize  that  they  are  hypertrophied.  ISTeither  do 
they  appear  to  be  increased  in  number.  The  interstitial  tissue  is 
considerably  thickened  and  studded  with  numerous  round  cells; 
those  ducts  of  the  glands  which  are  present  are  forced  apart  and 
separated  by  wide  intervals,  while  normally  they  lie  close  together 
(Fig.  38).  I  have  never  found  conditions  which  pointed  to  new 
formation  or  increase  (hyperplasia  or  hypertrophy)  of  the  glandu- 
lar substance.  In  the  great  majority  of  cases  the  mucous  mem- 
brane is  spread  smoothly  over  the  muscularis,  and  is  thinned  rather 
than  thickened  ;  yet  in  the  rare  forms  of  hypertrophic  dilata- 
tion the  condition  which  the  French  call  Hat  mammelone  is 
developed,  owing  to  the  unequal  growth  of  the  mucosa  and  the 
muscularis,  which  leads  to  the  former  being  thrown  up  into 
folds. 

At  first  the  dilatation  of  the  stomach  is  found  specially  at  the 
cul-de-sac  \  later  on  it  involves  the  whole  organ.  A  pathological 
curiosity  are  the  rare  dilatationlike  diverticula  which  are  due  to 
the  persistent  pressure  of  indigestible  substances  (coins,  etc.)  in  the 
stomach. 

Symptoms  of  Gastrectasis. — As  a  rule,  patients  with  dilatation  of 
the  stomach,  as  may  be  inferred  from  the  nature  of  its  causes,  are 
middle-aged  or  more  advanced  in  years.  Yet  the  more  extensive 
my  experience  becomes,  the  more  am  I  astonished  at  the  frequency 
with  which  it  occurs  in  younger  persons,  and  is  not  recognized. 


PATHOLOGY  OP  GASTRECTASIS. 


281 


According  to  Pauli,*  stenosis  of  the  pylorus  may  be  congenital  and 
may  give  rise  to  dilatation.  Andralf  speaks  of  children  being  bom 
with  stomachs  which  filled  the  greater  portion  of  the  abdominal 
cavity.     Similar  observations  have  frequently  been  made,  and  only 


Fig.  38. — Cross-section  through  the  mucous  membrane  of  a  dilated  stomach.  The  ducts 
of  the  glands  are  forced  apart,  the  interstices  entirely  filled  by  an  infiltration  of  small 
cells.  The  glandular  epithelium  is  unchanged  in  part,  partly  fatty,  and  in  some  places 
entirely  gone.  Single  epithelial  cells  may  be  seen  in  the  interstitial  tissue. — Camera 
lucida. 

a  short  time  ago  at  the  Augusta  Hospital  I  found  a  marked  dilata- 
tion of  the  stomach  in  a  girl  13  years  of  age  who  claimed  to  have 
heard  succussion  sounds  (which  were  very  evident  at  the  examina- 
tion) since  her  earliest  childhood.  During  the  past  few  years  I 
have  frequently  seen  cases  of  more  or  less  marked  dilatation  in 
young  patients  between  12  and  17  years  old,  in  none  of  which 
could  a  manifest  cause  for  its  origin  be  discovered.     Wiederhof er, :{: 


*  Pauli.     De  ventriculi  dilatatione.     Prankfurt  a.  M.,  1839. 

f  Andral.  Grundriss  der  pathol.  Anatomie.  Edited  by  Becker,  1830,  ii, 
S.  91. 

t  Wiederhofer.  Gerhardt's  Handb.  d.  Kinderkrankheiten.  Bd.  iv,  Abtheil.  ii, 
S.  356  et  seq. 


282 


DISEASES  OF  THE  STOMACH. 


Comby,*  Malibran,t  and  others,  have  demonstrated  and  carefully 
studied  dilatation  of  the  stomach  in  children  which  they  have 
ascribed  to  atonic  and  anaemic  conditions.  My  own  experience  in 
the  polyclinic  of  the  Augusta  Hospital  shows  that  marked  dilatation 
is  by  no  means  rare  in  children,  although  they  are  as  a  rule  so  well 
compensated  that  the  symptoms  presented  are  only  dyspeptic,  and 
not  those  due  to  fermentation. 

Before  discussing  the  symptomatology  of  dilatation,  I  wish  to 
state  that  we  not  infrequently  see  cases  which  present  the  typical 
clinical  picture  of  gastric  dilatation  and  yet  in  which  there  is  no 
true  dilatation  of  the  stomach.  I  shall  designate  such  cases,  as 
O.  Kosenbach  has  done,:}:  gastric  instifficiency,  or  better,  motor 
insufficiency,  of  the  stomach.  I  shall  again  refer  to  this  later  on. 
[Recently  most  writers  have  grouped  all  cases  of  gastrectasis  under 
the  general  heading  of  mechanical  insufficiency  of  the  stomach,  and 
have  subdivided  them  according  to  the  severity  of  the  motor  dis- 
turbance.] 

The  symptoms  of  dilatation  of  the  stomach  always  develop 
slowly.  As  a  rule,  dyspeptic  troubles  are  the  first  to  appear,  and 
they  may  last  for  years  ;  indeed,  they  may  be  the  only  symptom  of 
a  well-developed  dilatation.  Thus  it  is  that  the  latter  is  discovered 
only  on  a  very  careful  examination  of  the  patient.  This  occurred 
to  me  not  long  ago  in  a  young  man  whose  father,  a  physician,  had 
given  him  a  letter  with  an  explicit  description  of  the  symptoms  on 
which  he  had  based  the  diagnosis  of  nervous  dyspepsia.  In  addi- 
tion to  the  dyspeptic  difficulties — anorexia,  pressure  and  fullness 
after  eating,  tension  of  the  abdomen,  bad  odor  from  the  mouth, 
coated  tongue,  epigastric  tenderness,  malaise,  oppression  and  pain 
in  the  head,  irregular  stool,  etc. — we  have  a  characteristic  symptom 
in  vomiting.  At  first  this  occurs  frequently,  and  comparatively 
soon  after  eating,  being  to  a  certain  extent  a  therapeutic  effort  of 
the  organism  to  relieve  itself  of  the  excess  of  the  ingesta,  while  a 


*  Comby.  De  la  dilatation  de  I'estomac  chez  les  enfants.  Arch,  gener.  de  med., 
AoUt  et  Sept.,  1884. 

f  Malibran.  Contribution  a  I'etude  des  ectasies  gastriques.  These  de  Paris, 
J885, 

\  0.  Rosenbacbj  Iog  qU, 


SYMPTOMS  OF  GASTRECTASIS.  283 

portion  is  retained  in  the  stomacli,  as  urine  is  in  a  paralyzed  blad- 
der. Later  the  vomiting  occurs  less  frequently  in  proportion  to 
the  increasing  relaxation  of  the  muscle  and  as  the  quantity  of  the 
collected  masses  to  be  evacuated  becomes  greater ;  finally — and  this 
is  always  a  bad  omen — it  ceases  entirely.  Then  either  the  ob- 
structing neoplasm  has  ulcerated,  thus  again  opening  the  passage 
into  the  intestine,  or  a  complete  paralysis  of  the  muscle  has  been 
developed.  A  characteristic  feature  of  the  vomit  is  its  large  quan- 
tity, which  in  individual  cases  has  been  quite  astonishing,  and  is 
said  to  have  been  as  much  as  8  kilogrammes  [17f  pounds].  Portal 
says  that  the  stomach  of  the  Due  de  Chausnes,  one  of  the  greatest 
gourmands  in  Paris,  could  hold  eight  pints  of  fluid ;  and  even  larger 
figures  are  given.  [Liebermeister  *  gives  the  details  of  the  case  of 
a  hackman  who  was  noted  for  the  enormous  quantities  of  beer 
which  he  could  swallow  at  a  single  draught.  The  autopsy  which 
was  made  after  his  death  from  an  accident  showed  that  the  capacity 
was  6  litres  [13  pints],  but  otherwise  the  organ  was  normal. 

Characteristics  of  Stomach  Contents. — It  is  well  known  that  at 
times  more  is  vomited  than  has  been  eaten,  since  the  remnants  of 
former  meals  which  accumulate  in  the  stomach  are  added.  If  the 
vomit,  or  the  masses  removed  from  the  stomach  through  the  tube, 
are  allowed  to  stand  in  a  glass  cylinder,  they  soon  separate 
into  three  layers,  the  upper  one  of  brownish  foam,  a  much 
larger  middle  layer  of  yellowish-brown,  faintly  cloudy  fluid,  and  a 
lower  one  consisting  of  dark-brown,  crummy,  and  slimy  masses, 
chiefly  remains  of  food.  Prom  time  to  time  bubbles  of  gas  rise  up 
through  the  fluid,  carrying  particles  of  the  deposit  with  them,  while 
other  fragments  sink,  since  they  are  no  longer  supported  by  the 
carbonic-acid  gas.  Such  a  play  of  bubbles,  similar  to  that  which 
we  see  in  a  glass  of  champagne  in  which  bread  crumbs  have  been 
placed,  always  indicates  considerable  yeast  fermentation.  Further, 
we  find  the  morsels  of  food  in  the  vomit  in  a  more  or  less 
softened  and  digested  condition  ;  we  also  find  varieties  of  mucor, 
sarcinse,  yeast,  and  numberless  schizomycetes.     At  Kussmaul's  in- 


*  [Liebermeister.     Die  Krankheiten  des  Unterleibsorgane,  1894,  p.  70.     Quoted 
from  Boas. — Ed.] 


284  DISEASES  OP  THE  STOMACH. 

stigation  Du  Barry*  examined  these  vegetable  forms  more  care- 
fully, and  isolated  them  in  pure  cultures,  but,  it  is  to  be  regretted, 
without  obtaining  any  definite  pathognostic  result.  We  are  not 
justified,  from  the  observations  made  by  this  author,  in  inferring  a 
fermentative  action  from  the  presence  and  growth  of  the  fungi. 
At  all  events,  bacteria,  yeast,  and  probably  sarcinse  also  have  a 
definite  typical  fermentative  action.  Sarcinse  ventriculi,  those  pe- 
culiar colonies  of  cocci  which  occur  in  cubes  or  as  tetrads,  were  first 
described  by  Goodsir  in  1842 ;  the  extensive  literature  which  has 
been  written  about  them  since  then  has  been  collected  in  detail  by 
Falkenheim.f  [See  Fig.  41.]  It  is  a  matter  of  regret  that  the 
pathognostic  significance  of  the  parasite  does  not  deserve  the  in- 
terest which  was  accorded  to  it  by  physicians.  As  early  as  1849 
Frerichs  apologized  for  speaking  about  a  subject  "  the  literature  of 
which  is  perhaps  more  extensive  than  its  importance  warrants  "  ; 
thus  Falkenheim  also  was  unable  to  add  anything  new  as  to  their  oc- 
currence or  significance,  while  he  established  the  important  fact  in 
the  natural  history  of  sarcinse  that  at  times,  according  to  external 
circumstances,  the  same  cocci  may  form  either  irregular  masses  or 
typical  sarcinsB.  Usually  sarcinse  are  present  in  small  numbers  or 
are  entirely  absent,  yet  at  times  in  conditions  favorable  to  their 
growth  they  may  appear  in  large  masses,  so  that  every  drop  of 
stomach  contents  is  really  a  pure  culture  of  them ;  indeed,  F. 
Richter  j^.  reports  a  case  in  which  the  inspissated  masses  of  sarcinse 
had  led  to  complete  closure  of  the  pylorus.  [The  relations  of  sar- 
cinse  ventriculi  have  recently  been  studied  by  Oppler,*  who  found 
that  they  occurred  in  large  numbers  only  in  gastrectases  due  to 
benign  stenoses  of  the  pylorus  ;  where  the  cause  of  the  latter  is 
mahgnant  they  are  rarely  found.  Oppler  would  explain  this  by 
the  fact  that  sarcinse  only  thrive  in  the  presence  of  HCL]  How- 
ever, if  large  numbers  of  micro-organisms  are  present  in  the  stom- 
ach contents  in  spite  of  the  free  hydrochloric  acid,  or  if  the  reaction 

*  Du  Barry.     Beitrag  zur  Kenntniss  der  niederen  Organismen  ira  Mageninhalt. 
Arch.  f.  exp.  Pathol,  u.  Pharmacol.,  Bd,  xx,  p.  243. 

•)•  Falkenheim.     Ueber  Sarcine.     Arch.  f.  exp.  Pathol,  u.  Pharmacol.,  Bd.  xix. 
I  Richter.      Verstopfung  des  Pylorus  durch    Sarcina  ventriculi,     Virchow's 
Arch.,  Bd.  cvii,  p.  198. 

*  [Oppler.    Miinch.  med.  Wochenschr.,  1894,  No.  29.— Ed.] 


SYMPTOMS  OP  GASTRECTASIS.  285 

be  neutral,  or  if  the  acidity  be  due  to  organic  acids,  there  is  imme- 
diately such  a  development  of  fungi  in  the  jEiltrate  that  the  variety 
of  the  predominating  fermentation  may  be  recognized  even  by 
mere  inspection.  Thus  we  may  find  mold  fungi — and  this  even  in 
the  presence  of  the  hydrochloric-acid  reaction  in  the  filtrate — in  the 
form  of  a  white  or  gray  scum  upon  the  surface;  or,  after  being 
cloudy  at  first,  yeast  may  be  deposited  at  the  bottom  of  the  vessel ; 
or  a  more  equally  diffused  turbidity,  together  with  a  strong  sour 
odor,  may  be  produced  by  the  development  of  the  lactic,  acetic,  and 
butyric  acid  bacilh  ;  or,  finally,  white  zooglea  masses,  which  readily 
fall  apart,  may  form  upon  the  surface.  These  finally  lead  to  com- 
plete decomposition  of  the  albumen,  and  to  an  alkaline  reaction,  the 
process  being  accompanied  by  the  odor  of  decay. 

At  times  the  vomit  contains  remnants  of  food,  such  as  pits, 
fish  scales,  etc.,  which,  as  the  patients  can  prove,  had  been  eaten 
months  before.  Werner  *  found  17  plum  and  920  cherry  pits  in 
a  dilated  stomach,  which  must  have  stayed  there  since  the  previous 
cherry  season — i.  e.,  fully  three  quarters  of  a  year.  But  at  times 
such  things  remain  in  stomachs  which  are  not  dilated.  Thus 
in  the  stomach  contents  obtained  from  a  neurasthenic  I  found  a 
small  piece  of  fish  skin,  which,  according  to  the  positive  statements 
of  the  patient,  must  have  been  in  the  stomach  for  three  and  a  half 
days. 

The  chemical  relations  of  the  gastric  juice  in  gastrectasis  depend 
upon  the  cause  of  the  dilatation.  Should  a  cancer  be  present,  we 
will  find  all  the  anomalies  of  secretion,  which  will  be  explicitly  dis- 
cussed in  the  chapter  on  Carcinoma  of  the  Stomach.  If,  on  the 
other  hand,  we  have  to  deal  with  cicatricial  contractions  of  the 
pylorus,  atonic  conditions  of  the  muscular  fibers,  hypersecretion, 
etc.,  we  find  almost  without  exception  either  the  usual  or  increased 
quantities  of  hydrochloric  acid,  peptone,  and  propeptone,  and  the 
peptic  action  is  satisfactory,  though  usually  somewhat  retarded. 
But  even  in  the  same  patient  and  with  the  same  diet  the  quantity 
of  HCl  may  vary  on  different  days,  so  that  variations  from  O'OY  per 
cent  to  0'28  per  cent  may  be  found.     It  is  by  no  means  rare  to  find 

*  Werner.    Znr  Casuistik  des  Mageiikrebses,  etc.     Wurtemberg.  med.  Corre- 
spondenzbL,  1869,  23-24. 


236  DISEASES   OP  THE  STOMACH. 

hypersecretion  (hypersecretio  acida  continua),  so  tliat  after  empty- 
ing the  stomach  in  the  evening,  on  the  following  morning  we  may 
obtain  fluid  containing  HCl  sometimes  in  considerable  amounts.  In 
33  cases  Eiegel*  found  O'lO  to  0-46  per  cent  HCl;  in  68  cases 
which  I  titrated,  the  acidity  due  to  hydrochloric  acid  varied  be- 
tween 50  and  80  =  0-lY  to  0-30  per  cent  of  that  acid. 

rermentations. — However,  this  picture  of  the  normal  condition 
of  secretion  is  complicated  by  the  fermentations  which  take  place  in 
the  stomach,  and  which  cause  secondary  decompositions  of  the  stom- 
ach contents.  In  another  place  f  I  have  given  the  schema  of  the 
fermentation  of  carbohydrates,  which,  depending  upon  the  abnormal 
decomposition  of  sugar,  appears  at  times  in  the  form  of  the  so-called 
oxidation-fermentation,  alcohol,  aldehyde,  and  acetic  acid  being 
formed  from  the  sugar ;  or  at  other  times  lactic  acid  fermentation 
sets  in,  in  which  the  sugar  is  first  decomposed  into  lactic  acid,  and 
later  into  butyric  acid,  carbon  dioxide,  and  hydrogen.  Both  fer- 
mentative processes  are  due  to  the  presence  of  specific  organized  fer- 
ments, among  which  we  can  name  yeast,  oidium  lactis,  and  a  num- 
ber of  bacteria,  the  recognition  and  isolation  of  which  are  to  be 
especially  ascribed  to  Hiippe.  Both  processes  may  occur  together, 
and  in  rare  cases  may  be  combined  with  the  products  of  cellulose 
fermentation  ;  though  it  is  questionable  whether  the  latter — namely, 
methane,  and  sometimes  olefiant  gas — are  derived  from  the  stomach, 
or  whether  they  have  not  rather  regurgitated  from  the  intestines 
into  the  stomach.  The  best -known  case  of  this  kind  is  that  de- 
scribed by  Ruppstein  and  myself,:}:  of  a  patient  who,  according  to 
his  own  statement,  "  had  at  times  a  vinegar  factory  and  at  others  a 
gas  factory  in  his  stomach,"  in  whom,  therefore,  the  fermentation 
was  sometimes  combined  with  a  predominant  production  of  acid,  and 
at  other  times  caused  a  collection  of  gas.  When  the  latter  condition 
was  present,  he  could  ignite  the  eructated  gases  through  a  little  roll 

*  Riegel.  Beitrage  zur  Diagnostik  und  Therapie  der  Magenkrankheiten.  Zeit- 
schr.  f.  klin.  Med.,  Bd.  xi,  Hefte  2  u.  8. 

f  Ewald.  Klinik,  etc.  I.  Theil.  3te  Auflage,  S.  135.  [See  also  Boas,  Therap. 
Monatshefte,  January  and  February,  1896,  for  a  good  resume  of  the  fermentation 
and  changes  in  the  stomach  contents  in  gastrectases. — Bd.] 

X  Ewald.  Ueber  Magengahrung  und  Biklung  von  Magengasen  mit  gelb  bren- 
nender  Flamme.    Reichert's  und  Du  Bois'  Archiv,  1874,  S.  317. 


SYMPTOMS  OP  GASTRECTASIS.  287 

of  paper  or  a  cigar-holder,  by  holding  a  lighted  match  in  front  of 
it ;  the  result  was  a  faintly  illuminating  flame.  In  the  vomit  Eupp- 
stein  demonstrated  the  presence  of  alcohol,  acetic,  lactic,  and  butyric 
acids,  while  I  found  the  gases  to  be  composed  of  carbon  dioxide, 
hydrogen,  methane,  traces  of  olefiant  gas,  oxygen,  nitrogen,  and  sul- 
phureted  hydrogen.  Similar  observations  have  been  made  by 
Schultze,  Heynsius,  and  Popoff ;  a  gas-forming  bacillus  has  been 
isolated  from  the  stomach  contents  by  Miller,  the  activity  of  which 
only  ceases  in  1-6  per  mille  HCl.  The  gas  produced  contained  only 
Co,  and  H.  A  similar  case  of  McI^Taught's  has  already  been  referred 
to  (page  161).  The  formation  of  gases  in  the  contents  of  dilated 
and  catarrhal  stomachs  has  been  systematically  studied  by  both  G. 
Hoppe-Seyler  and  Kuhn."^  According  to  the  former,  the  occur- 
rence of  inflammable  gas  is  by  no  means  a  rarity,  for  in  13  out  of 
22  cases  he  could  obtain  a  gas  from  the  stomach  which  consisted  of 
a  mixture  of  Co,  and  H  ;  the  amount  of  the  latter  was  as  high  as 
60  per  cent,  and  was  the  result  of  butyric  acid  fermentation  which 
may  take  place  even  when  there  is  as  much  as  0*2  per  cent  HCl. 
The  same  conclusions  were  reached  by  Kuhn  (who  studied  the  gases 
which  developed  in.  the  stomach  contents  after  their  removal,  the 
organisms  of  fermentation,  etc.).  The  methods  used  by  both  of 
these  investigators  are  too  complicated  for  general  practice.  [Strauss 
has  recently  shown  that  the  bacillus  coli  communis  produces  gas 
when  grown  on  culture  media  containing  sugar  (see  page  45)]. 

But  we  may  easily  ascertain  whether  there  are  gases  in  any 
stomach  contents,  the  intensity  of  their  formation,  and  whether  they 
consist  only  of  Co„  or  of  other  gases  (the  most  important  of  which 
is  hydrogen).  This  is  done  by  filling  two  ordinary  fermentation 
tubes  (the  best  is  Einhorn's  fermentation  saccharimeter)  with  stom- 
ach contents,  in  the  one  unfiltered,  in  the  other  filtered,  putting 
them  aside  at  ordinary  temperature  and  observing  the  rapidity  of 
the  formation  of  gas.  After  this  has  ceased  add  some  caustic  pot- 
ash, which  on  account  of  its  weight  will  sink,  and  may  thus  be  easily 


*  G.  Hoppe-Seyler.  Deutsch.  Arch,  ftir  klin.  Med.,  Bd.  1,  p.  82.— Kiihn.  Zeit- 
sehr.  fiir  klin.  Med.,  Bd.  xxi,  p.  572 ;  Deutsche  raed.  Wochenschr.,  1892,  Nos.  49, 
50.— [Strauss.  Zeitschr.  fiir  klin.  Med.,  Bd.  sxvi  and  xxvii.  See  also  literature 
quoted  on  page  55. — Ed.] 


288  DISEASES  OF  THE  STOMACH. 

introduced  into  the  graduated  portion  of  the  apparatus.  If  the  gas 
disappears  after  a  time  and  the  graduated  part  of  the  tube  refills  en- 
tirely, then  the  only  gas  present  is  CO^. 

In  view  of  what  has  already  been  said,  it  seems  to  me  to  be  a 
strange  coincidence  that  in  my  former  and  present  investigations  I 
have  never  seen  any  hydrogen  fermentation.  It  is  also  remarkable 
that  the  total  acidity  is  not  excessive  even  in  cases  of  very  marked 
fermentation  in  spite  of  the  intense  odor  and  acridity  of  the  regur- 
gitated or  vomited  stomach  contents.  This  is  undoubtedly  due  to 
the  fact  that  the  acids  which  are  formed  are  immediately  converted 
into  neutral  or  basic  salts.  Another  form  of  abnormal  chemical 
change  leads  to  the  products  of  decomposition  of  albumen — amido- 
acids  and  ammonia — which  are  characterized  by  their  peculiar  f  ou] 
odor,  and  under  the  microscope  by  the  prevalence  of  cocci,  vibri- 
ones,  and  masses  of  zooglea,  some  of  which  may  be  seen  spinning 
about  in  the  field  in  a  lively  manner.  Betz,  Senator,  Ewald,  Em- 
minghaus.  Boas  *  [Strauss,  and  others]  have  demonstrated  the  occur- 
rence of  sulphureted  hydrogen  in  the  stomach  contents ;  Boas 
claims  that  its  presence  is  quite  common  where  albumens  are  de- 
composed. It  may  be  detected  with  acetate  of  lead  paper  moistened 
with  caustic  potash.  The  reaction  of  the  stomach  contents  is,  then, 
usually  neutral ;  or,  if  the  basic  products  of  the  decomposition  of 
albumen  are  in  excess,  it  may  even  be  faintly  alkaline.  Still,  as 
already  mentioned,  the  decomposition  of  proteids  may  occur  even  if 
HCl  is  present,  or  may  be  absent  even  when  no  HCl  is  found.  At 
any  rate,  because  there  is  either  an  absence  of  hydrochloric  acid 
from  the  commencement,  or  because  it  is  neutralized  by  the  prod- 
ucts of  decomposition  spoken  of,  an  opportunity  is  given  for  pro- 
gressive decompositions  which  combine  with  the  above-mentioned 
processes  of  fermentation,  and  thus  may  produce  very  varied 
clinical  pictures.  Usually  in  such  cases  we  have  to  deal  with 
large  degenerating  neoplasms.  [Boas  f  and  others  claim  that  as 
a  rule  the  total  acidity  is  considerably  increased  in  most  cases 
of  stagnation  and  decomposition  of  the  stomach  contents,  the  high 

*  Boas.     Ueber  das  Vorkommen  von  SchwefelwasserstofE  im  Magen.     Deutsch. 
med.  Wochenschr.,  1892,  No.  49. 

f  [Boas.     Op.  cit.,  Bd.  ii,  p.  99.— Ed.] 


SYMPTOMS  OF  GASTRECTASIS.  289 

total  acidity  being  due  either  to  free  or  combined  HCl  and  organic 
acids. 

Concerning  the  presence  of  acetone,  toxines,  etc.,  see  pages 
45,  46]. 

■  While  the  stagnation  of  the  stomach  contents  exerts  no  appreci- 
able influence  upon  the  secretion  of  the  mucous  membrane  as  long 
as  the  secreting  elements  are  intact,  it  disturbs  absorption  very  seri- 
ously. This  goes  hand  in  hand  with  the  paresis  of  the  motor  ele- 
ments. The  tests  with  iodide  of  potassium  and  with  salol  show  the 
retardation  of  the  absorptive  and  motor  functions.  The  result  of 
the  former  may  be  obtained  from  half  an  hour  to  a  whole  hour  too 
late,  and  I  have  seen  the  latter  absent  as  long  as  two  and  three 
hours.  Nevertheless,  it  is  by  no  means  asserted  that,  in  all  or  in 
particular  cases  of  gastric  dilatation,  these  reactions  are  always  typi- 
cally retarded.  It  must  be  borne  in  mind,  however,  that  they 
explain  only  a  function,  and  not  a  group  of  symptoms,  and  that 
a  markedly  dilated  stomach  can  very  well  display  normal  or  nearly 
normal  efficiency  in  this  direction.  But,  under  such  circumstances, 
the  disturbances  which  might  otherwise  develop  tend,  as  a  rule,  to 
be  comparatively  shght.  Thus  in  fourteen  cases  of  typical  dilata- 
tion of  the  stomach,  in  which  I  used  the  salol  test,  I  found  in  five 
that  there  was  no  appreciable  delay  in  the  splitting  up  of  the  salol. 
In  three  of  these  cases,  too,  the  subjective  symptoms  of  dilatation 
of  the  stomach  were  by  no  means  marked,  proving  that  the  ingesta 
were  promptly  passed  on  into  the  intestine,  thus  compensating  for 
the  dilatation. 

[In  this  connection  it  is  well  to  recall  the  researches  of  Yon  Me- 
ring,*  who  showed  that  when  there  is  stagnation  of  the  chyme,  ab- 
sorption of  liquids  is  not  alone  delayed,  but  that  there  is  also  a  trans- 
udation of  fluid  from  the  gastric  mucosa  as  the  result  of  the  irritation 
of  the  latter  by  the  various  ingredients  of  the  stagnating  food.] 

It  is  very  apparent  that  these  different  disturbances  of  function 
react  one  upon  the  other.  The  development  of  the  products  of  de- 
composition paralyzes  the  muscularis,  and  this  paralysis  favors  the 
stagnation  and  with  it  the  further  decomposition  of  the  ingesta. 

*  [See  p.  76.] 


290  DISEASES  OP  THE  STOMACH. 

The  disturbed  function  of  absorption  not  only  delays  the  removal 
of  absorbable  substances,  but  also  interferes  with  their  further  for- 
mation. In  view  of  the  experiments  of  Schmidt-Miihlheim,  Calm, 
and  others,  we  must  assume  that  the  power  of  the  gastric  juice  to 
form  peptone  ceases  as  soon  as  the  percentage  of  the  latter  has 
reached  a  certain  height,  just  as  alcoholic  fermentation  is  suspended 
as  soon  as  a  definite  quantity  of  alcohol  has  been  formed.  ISTow, 
since  the  peptones  are  neither  absorbed  nor  transferred  to  the  intes- 
tines at  the  proper  time,  it  follows  that  the  rest  of  the  nitrogenous 
food  is  not  attacked  by  the  gastric  juice;  and  hence  we  find  so 
many  wholly  or  partly  undigested  masses  in  the  stomach  in  spite  of 
the  excessively  long  time  during  which  the  ingesta  remain  in  the 
organ. 

On  the  other  hand,  it  is  evident  that  all  these  conditions  may 
be  present  and  may  manifest  themselves  without  the  existence  of  a 
really  marked  dilatation,  but  rather  of  motor  insuflaciency,  or  what 
the  ancients  called  atony  of  the  stomach.  They  are  then,  it  is  true, 
less  marked,  yet  at  times  they  may  reach  a  high  degree  of  intensity, 
as  the  case  spoken  of  above,  of  the  patient  "  with  the  gas-factory," 
proves,  in  whom,  quite  contrary  to  our  assumption  of  a  dilatation 
of  the  stomach,  based,  it  is  true,  upon  what  we  would  to-day  con- 
sider insufiicient  examination,  there  existed  an  almost  concentric 
hypertrophy  of  the  stomach  with  a  stenosing  carcinoma  of  the  py- 
lorus.* Such  cases,  therefore,  as  I  have  mentioned  above  must  be 
designated  motor  insufficiency  of  the  stomach.f  From  these  con- 
siderations we  can  see  that  very  appreciable  dilatations  of  the  stom- 
ach may  occur,  in  which  the  injurious  effects  are  equalized  by  effi- 
cient compensation  on  the  part  of  the  absorptive  and  motor  functions. 
Thus,  some  individuals  may  for  years  have  an  abnormally  large 
stomach,  which  causes  them  little  or  no  trouble,  just  as  many  peo- 
ple live  for  years  with  valvular  lesions  in  ignorance  of  the  existence 
of  their  trouble,  since  compensatory  hypertrophy  of  the  ventricle 
equalizes  the  defect  of  the  valve.     But  some  day  this  compensation 

*  A  similar  anatomical  case  was  described  by  Diemerbroeek  in  1685  (and  cited 
by  Penzoldt,  Die  Magenerweiterungen)  in  order  to  prove  that  a  hard  drinker  must 
not  necessarily  have  a  dilatation. 

f  [Additional  cases  of  mechanical  insufficiency  in  spite  of  the  normal  size  and 
situation  may  be  found  in  Boas,  op.  cit.,  Bd.  ii,  p.  96. — Ed.] 


SYMPTOMS  OF  GASTRECTASIS.  291 

fails,  and  then  suddenly,  or  in  a  surprisingly  short  time,  all  the 
symptoms  of  dilatation  appear.  These  are  the  cases  in  which  the 
dilatation  has  apparently  arisen  acutely,  and  which  are  spoken  of 
especially  in  English  literature.*     [See  page  26T.] 

As  the  disease  progresses  the  nutrition  is  affected  more  and 
more ;  a  highly  marked  marasmus  appears.  The  hands  and  feet 
become  bluish-red,  cold,  and  moist ;  while  the  face  not  infrequently 
becomes  reddened  by  the  development  of  acne  pustules  and  marked 
ingestion  of  the  capillaries.  While  vomiting  occurs  less  frequently, 
the  foul-smelling  eructations  and  flatulence  are  increased.  The 
pressure  of  the  dilated  stomach  causes  displacements  of  the  neigh- 
boring organs,  especially  the  lungs,  heart,  liver,  and  intestines, 
together  with  disturbances  of  their  functions.  Dyspnoea  and  pal- 
pitation are  increased  according  to  the  extent  to  which  the  dia- 
phragm is  forced  upward  by  the  stomach  filled  with  ingesta  or  dis- 
tended by  gases.  Obstructions  to  the  portal  circulation  and  their 
consequences  appear.  The  bowels,  as  a  rule,  are  sluggish,  and  can 
be  moved  only  by  enemata  or  strong  drastics ;  and  the  stools  even 
then  are  usually  not  soft,  but  consist  of  hard  masses  mixed  with 
water  and  mucus.  An  unusual  symptom,  but  when  present  a  very 
conspicuous  one,  is  the  peristaltic  unrest  of  the  stomach,  first  de- 
scribed by  Kussmaul.  Powerful  waves  are  seen  passing  slowly  over 
the  stomach  from  right  to  left,  and  from  above  downward ;  they 
may  also  affect  the  lower  sections  of  the  intestines,  and  even  in  rare 
cases  take  an  antiperistaltic  course  (Cahn).  ISTaturally,  this  presup- 
poses a  marked  obstruction  at  the  pylorus  in  connection  with  rela- 
tively intact  muscle  or  innervation. f 

Kot  only  is  absorption  scanty  or  checked  in  the  stomach,  but  it 
must  also  be  markedly  diminished  in  the  intestine,  which  is  but 
insufficiently  provided  with  chyme  from  the  stomach  at  long  inter- 
vals. This  is  especially  true  of  the  absorption  of  water,  causing  an 
abnormal  dryness  of  the  muscular  and  nervous  tissues  and  of  the 

*  For  example,  Hilton  Fagge.  On  Acute  Dilatation  of  the  Stomach,  Guy's  Hosp. 
Reports,  xviii,  pp.  1-22  ;  and  Albutt,  On  Gastrectasis,  Lancet,  1887.  Hood.  A  Case 
of  Acute  Dilatation  of  the  Stomach,     Lancet,  December  19,  1891. 

t  [According  to  Osier  (loc.  cit.,  p.  25),  increased  peristalsis  is  not  infrequently 
seen  in  dilatation  of  the  stomach. — Ed.] 


292  DISEASES  OP  THE  STOMACH. 

skin ;  tliei  latter  is  rougliened  almost  as  it  is  in  the  last  stages  of  dia- 
betes, and  at  times  thickly  covered  with  furfuraceous  scales.  To 
this  dryness  Kussmaul*  ascribes  a  nervous  phenomenon  observed 
by  him  which  manifested  itself  by  painful  spasms  of  the  flexors  of 
the  arms,  the  calves,  and  the  abdominal  muscles,  with  which  at  times 
a  kind  of  nystagmus,  mydriasis,  emprosthotonos,  as  well  as  disturb- 
ances of  consciousness,  were  associated,  together  with  a  condition 
which  closely  resembled,  if  it  really  was  not,  the  tetany  which  ap- 
pears after  acute  infections,  rheumatism,  conditions  of  great  exhaus- 
tion, etc.  These  attacks  begin  with  painful  sensations  in  the  stom- 
ach and  other  regions  of  the  body,  as  well  as  with  a  feeling  of 
oppression,  and  may  at  times  last  for  many  hours.  The  face  may 
also  become  involved ;  it  then  assumes  a  masklike,  rigid  appearance. 
Temperature  and  pulse  are  often  very  high ;  and  in  a  short  time  all 
the  symptoms  may  become  so  very  much  aggravated  that  death 
speedily  results.  [The  symptoms  usually  occur  in  attacks  of  vary- 
ing duration  which  come  on  at  irregular  intervals.  As  a  rule  they 
appear  after  severe  vomiting.] 

According  to  this,  it  seems  that  the  disturbed  absorption  of  water 
and  the  resultant  dryness  of  the  tissues  may  in  individual  cases  be 
the  cause  of  an  abnormal  irritability  of  the  nervous  system  which 
may  become  intensified  sufficiently  to  present  the  picture  of  tetany, 
so  that  in  addition  to  the  symptoms  already  described  we  may  also 
find  a  decided  increase  in  the  mechanical  and  electrical  irritability 
of  the  nerves  and  muscles.  Trousseau's  symptom  and  the  facial 
phenomenon  may  also  be  present.  In  other  cases,  however,  owing 
to  the  absorption  into  the  blood  of  the  products  of  decomposition, 
there  may  appear  an  auto-infection  characterized  by  nervous  de- 
pression, which  has  been  aptly  named  coTna  dyspepticum.  Fr. 
Miiller  f  has  reported  two  cases  of  the  former  kind  in  which,  in 
addition  to  the  symptoms  already  mentioned,  there  was  a  distinct 

*  Kussmaul.  Ueber  die  Behandlung  der  Magenerweiterung,  etc.  Deutsch.  Arch, 
f.  klin.  Med.,  Bd.  vi,  S.  455.  Also  Laprevotte,  Des  accidents  tetaniformes  dans  la  di- 
latation de  Pestomac.  Paris,  1884. — Dujardin-Beaumetz  et  Oettinger.  Note  sur  un 
cas  de  dilatation  de  I'estomac  continuee  de  tetanie  generalisee.  L'Union  med.,  1884, 
Nos.  15  and  18. 

t  Fr.  Miiller.  Tetanie  bei  Dilatatio  ventriculi  und  Achsendrehung  des  Magens^ 
Charite-Annalen,  1888,  Bd.  xiii,  S.  273. 


SYMPTOMS  OF  GASTRECTASIS.  293 

increase  in  tlie  mechanical  and  electrical  excitability  of  nerve  and 
muscle ;  Minkowski  ^  mentions  the  occurrence  of  deep  coma  in  the 
course  of  a  case  of  dilatation  of  the  stomach,  the  patient  dying  in 
this  state  two  days  later ;  while  Litten  observed  similar  though  not 
such  intense  conditions  in  cases  of  acutely  developed  dyspepsia,  and 
obtained  the  ethyl -diacetic-acid  reaction  [Gerhardt's  Burgundy-red 
reaction]  in  the  urine.f  During  the  last  few  years  quite  a  number 
of  cases  of  tetany  after  gastric  dilatation  have  been  reported,  so  that 
Bouveret  and  Devicij:  have  been  able  to  present  an  exhaustive 
analysis  of  23  cases.  In  their  opinion  there  has  usually  been  a 
continuous  hypersecretion,  although  at  times,  and  especially  toward 
the  end  of  the  disease,  this  may  be  absent.  Although  Miiller  was 
unable  to  isolate  any  toxine  from  the  stomach  contents,  Bouveret  and 
Devic  succeeded  in  producing  symptoms  of  tetany  in  animals  by 
intravenous  injections  of  the  alcoholic  extract  of  the  stomach  con- 
tents of  such  cases,  and  especially  when  the  chyme  contained  a 
marked  excess  of  free  HCl.  It  remains  to  be  seen  how  far  these 
somewhat  surprising  statements  will  be  verified.  In  a  case  of  my 
own,  in  which  the  attack  occurred  immediately  after  the  introduc- 
tion of  a  stomach  tube,  the  amount  of  HCl,  instead  of  being  in- 
creased, was  much  diminished.  Finally,  therefore,  the  possibility 
remains  that  this  form  of  tetany  represents  a  reflex  process  proceed- 
ing from  the  stomach,  and  for  which  many  analogies,  collected  by 
Miiller,  could  be  found,  of  which  I  will  only  mention  the  convul- 
sions caused  by  worms.  [Fleiner  *  has  recently  published  an  ex- 
haustive essay  on  tetany  in  which  he  reports  four  cases  of  his  own. 
He  objects  to  the  name  tetany  because  the  group  of  symptoms  is 
unlike  that  disease  in  many  respects,  and  the  symptoms  present  in 
diiferent  attacks  even  in  the  same  persons  are  not  always  the  same. 
Thus  once  they  may  resemble  tetany,  at  another  time  tetanus,  and 

*  Minkowski,  loc.  cit.,  p.  163. 

f  M.  Litten.  Eigenartiger  Symptomeneoraplex  in  Folge  von  Selbstinfeetion  bei 
dyspeptischen  Zustanden.  Zeitschr,  f.  klin.  Med.,  Bd.  vii.  Supplementheft,  S. 
■81  u.  ff. 

X  Bouveret  et  Devic.  Recherches  cliniques  et  experimentelles  sur  la  tetanie 
d'origine  gastrique.  Eev.  de  med.,  1892,  Nos.  1  and  2.  An  exhaustive  bibliogra- 
piiy  is  given  here. 

*  [Fleiner.  Boas'  Archiv,  1895,  Bd.  i,  pp.  243-262.  Contains  full  bibliography. 
—Ed.] 


294  DISEASES  OP  THE  STOMACH. 

finally  the  attacks  may  be  epileptiform.  He  also  denies  the  assertion 
of  Bouveret  and  Devic  that  hypersecretion  and  hyperchlorhydria  are 
present  in  all  cases  of  tetany ;  in  one  of  his  cases  there  was  no  free 
HCl.  ISTeither  was  he  able  to  extract  any  preformed  toxine  from  the 
stomach  contents,  and  he  believes  that  the  substances  extracted  by 
Bouveret  and  Devic  were  due  to  faulty  chemical  manipulations.  He 
also  shows  that  Kussmaul  himself  has  discarded  his  original  belief 
that  tetany  was  due  to  a  rapid  thickening  of  the  blood  and  drying 
of  the  nerves  and  muscles.  His  own  views  are  that  the  cause  is  a 
reflex  action  and  not  originally  an  autointoxication ;  that  the  etio- 
logical factor  is  not  always  the  same,  but  that  "  in  most  cases  of 
convulsions  and  tonic  muscular  spasms  of  gastric  origin  which  may 
resemble  epilepsy,  tetanus,  or  tetany,  there  are  severe  anatomical 
changes  in  the  pyloric  region  of  the  stomach  or  duodenum  which 
more  or  less  completely  prevent  the  passage  of  the  chyme  into  the 
intestines  and  at  times  render  it  impassible,  and  then  produce  the 
condition  of  so-called  hypersecretion."]  Tetany  is  always  a  severe 
complication  of  gastric  dilatation,  for  of  the  23  cases  collected,  16 
were  fatal — a  mortality  of  69-5  per  cent. 

The  Urine. — I  have  never  observed  the  peptonuria  spoken  of 
by  G.  See  and  found  by  Bouchard  in  7  per  cent  of  his  cases,  al- 
though 1  have  examined  many  patients  for  that  purpose.  The 
bodies  found  were  probably  albumoses,  and  not  peptone.  At  times, 
in  the  later  stages  of  the  disease,  the  quantity  of  the  urine  is  dimin- 
ished, though  this  is  not  usual.  Perhaps  this,  like  the  alkalinity  of 
the  urine,  which  may  be  observed  under  certain  circumstances,*  is 
to  be  referred  to  the  regular  emptying  or  washing  of  the  stomach 
undertaken  in  the  course  of  treatment.  Quincke  believes  the  cause 
to  be  the  deficient  absorption  of  the  acid  of  the  stomach  by  the  gas- 
tric mucosa,  whereby  an  important  factor  in  the  acidifying  of  the 
urine  is  removed.  This  is  quite  possible  so  long  as  the  changes  in 
the  chemical  functions  connected  with  dilatation  are  not  remedied. 
On  the  contrary,  it  seems  to  me  that  the  greater  the  care  which  is 
taken  to  improve  the  organ  by  systematic  lavage,  the  more  favor- 

*  Quincke.  Dilatatio  ventriculi  mit  Durchbruch  in  das  Colon.  Eigenthiim- 
liches  Verhalten  des  Urins.  Correspondenzbl.  fiir  Schweizer  Aerzte,  1874, 
No.  1. 


DIAGNOSIS  OP  GASTEECTASIS.  295 

able  must  the  conditions  of  absorption  become,  and  that  therefore  the 
urine  should  be  acid  rather  than  alkaline.  This  is  also  con-oborated 
bj  an  observation  of  Winkhaus,*  who  collected  the  urine  in  sepa- 
rate portions  at  various  periods  during  the  day  in  a  patient  with  a 
marked  gastrectasis  ;  the  urine  was  alkaline  as  long  as  the  fermenta- 
tion in  the  stomach  was  not  interfered  with,  but  invariably  became 
acid  some  time  after  the  stomach  was  washed  out.  Moreover,  it  de- 
pends entirely  on  the  actual  cause  of  the  dilatation  whether  any 
quantities  of  hydrochloric  acid  worth  mentioning  are  secreted  by  the 
stomach.  Besides  triple  phosphates,  crystals  of  magnesium  phos- 
phates, i.  e.,  large  highly  refracting  rhombic  plates  have  been  found. 
[In  cases  of  tetany,  increased  toxicity  of  the  urine  has  been  reported 
by  Bouveret  and  Devic  and  others.f  Albumen,  and  sometimes  sugar, 
have  also  been  found  in  this  condition.] 

Diagnosis. — Were  I  to  follow  the  usual  plan  and  now  take  up 
the  diagnosis  of  dilatation  of  the  stomach,  I  would  simply  have  to 
repeat  what  has  already  been  said,  for  whatever  has  reference  to 
the  diagnosis  has  been  fully  discussed.  It  is  just  in  dilatation  of 
the  stomach  that  the  diiferential  diagnosis  is  relegated  more  than 
elsewhere  to  the  background.  According  to  Loreta,  catarrhal  dila- 
tation may  be  distinguished  from  that  after  cicatricial  stricture  of 
the  pylorus  by  the  occurrence  of  large  quantities  of  undigested  food 
in  the  wash  water  in  lavage  in  the  former,  whereas  in  the  latter  the 
stomach  contents  are  an  acid  chyme.  In  the  former  the  appetite 
may  be  present ;  in  the  latter  it  is  changed.:]:  In  some  stages  of 
dilatation,  as  my  own  experience  shows,  this  is  perfectly  true.  But 
the  amount  of  HCl  diminishes  *  as  the  mucosa  becomes  more  and 
more  involved  by  chronic  inflammatory  changes. 

It  is  self-evident  that  we  must  guard  against  confounding  this 
condition  with  distention  of  the  colon,  ovarian  cysts,  sacculated 
ascites,  hydronephrosis,  and  echinococcus  cysts ;  however,  on  care- 
ful examination  by  the  methods  given,  these  can  hardly  claim  our 

*  H.  Winkhaus.     Beitrag  zur  Lehre  Ton  der  Magenerweiterung.     Inaug.  Diss., 
Marburg,  1887. 

f  [Loc.  cit.] 

X  Quoted  by  Marten,  Lancet,  August  2,  1890. 

*  In  one  case  I  found  the  acidity  as  high  as  98,  although  lactic  and  butyric  acids 
were  absent. 

20 


296  DISEASES  OF  THE  STOMACH. 

earnest  attention.  The  differentiation  of  gastroptosis  from  dilata- 
tion will  te  considered  wliile  discussing  the  former  condition.  On 
the  whole,  the  tendency  of  physicians  is  to  make  the  diagnosis  of 
"  dilatation  of  the  stomach  "  rather  too  often  than  too  seldom,  ex- 
cept, as  I  have  already  mentioned,  when  it  occurs  in  young  persons. 
It  would  be  of  very  great  importance  were  we  able  to  sharply  dis- 
tinguish between  insufficiency  of  the  stomach  and  true  gastrectasis. 
This  is  easy  as  long  as  we  have  to  deal  with  the  group  of  symptoms 
of  a  dilatation  when  no  truly  dilated  stomach  is  present ;  under  such 
circumstances  it  may  be  extremely  difficult  to  exclude  a  primary  ca- 
tarrhal condition ;  yet  it  is  impossible,  and  the  diagnosis  can  only 
be  made  ex  juvantihus  when,  with  a  relatively  short  duration  of  the 
disease  and  poorly  marked  symptoms,  a  megalogastria  exists  at  the 
same  time,  and  thus  simulates  an  incipient  gastrectasis.  In  advanced 
cases  we  can  not  remain  in  doubt  even  under  such  circumstances. 

Course  and  Prognosis. — Both  are  intimately  connected  with  the 
primary  cause  of  the  gastric  dilatation.  If  it  be  due  to  a  malignant 
tumor,  the  duration  of  life  is  dependent  upon  the  course  of  the  can- 
cerous disease  and  the  prognosis  is  always  unfavorable ;  yet  we  must 
not  forget  that  remissions  may  occur  in  the  course  of  such  processes 
which  under  the  influence  of  rational  treatment  may  produce  a  rela- 
tively good  condition  for  weeks,  and  even  for  months.  It  is  to  this 
fact  that  the  majority  of  the  cases  reported  "  cured  "  can  probably 
be  referred.  I,  however,  have  never  seen  such  a  gastric  dilatation 
cured,  but  I  have  repeatedly  observed  that  such  periods  of  improve- 
ment threw  doubt  upon  the  diagnosis  till  it  was  finally  confirmed  at 
the  autopsy. 

When  the  dilatations  are  caused  by  constricting  cicatrices,  or  by 
atonic  conditions  of  the  gastric  muscle,  they  run  a  slower  course, 
and  the  prognosis  is  on  the  whole  more  favorable.  But  here  too, 
alas  !  we  must  say,  "  PrcBvalabunt  fata,  consiliis  !  "  Such  patients 
carry  their  dilated  stomachs  about  with  them  for  years,  and  under 
appropriate  treatment  and  diet  can  lead  an  endurable  life — indeed, 
one  almost  free  from  all  difficulties  ;  but  they  never  dare  forget  that 
every  "  step  from  the  path  " — i.  e.,  every  dietetic  error — which  need 
by  no  means  be  gross,  but  simply  a  very  slight  departure  from  the 
presfcribed  diet,  entails  not  only  a  momentary  feeling  of  sickness 


PROGNOSIS  OF  GASTRECTASIS.  297 

but  Tisiially  severe  disturbances,  wbicb  sometimes  can  not  be  relieved 
at  all ;  for  it  is  a  peculiar  characteristic  of  all  dyspeptic  conditions 
of  a  severe  and  chronic  nature  that  they  not  only  may  relapse 
easily,  but  that  these  relapses  last  longer  and  are  worse  than  the 
first  attack.  But  it  nmst  be  specially  emphasized  that  dilata- 
tions of  the  stomach  when  they  are  recognized  early  offer  us  a 
very  grateful  field  for  treatment,  unless,  which  is  not  unusually 
the  case,  they  have  been  treated  in  the  meantime  with  every  kind 
of  purposeless  "  stomach  medicines."  We  can  very  safely  promise 
such  patients  a  very  marked  improvement  in  their  trouble ;  in  fact, 
were  we  only  to  regard  the  subjective  symptoms,  we  could  promise 
a  cure.  But.  if  we  did,  such  a  falsehood  would  be  punished  in  the 
future.  As  far  as  my  experience  goes,  even  these  dilatations  can 
not  be  cured,  and  the  final  prognosis  is  always  unfavorable ;  at 
least,  in  four  cases  which  I  have  had  the  opportunity  of  watching 
ior  years — over  10  and  as  long  as  12  years — I  have  found  the 
stomach  just  as  large  as  ever  when  I  distended  it,  in  spite  of  sub- 
jective improvements  and  even  apparent  cure ;  the  result  has  been 
just  the  same  in  the  many  cases  of  dilatation  of  the  stomach  of  this 
category  which  I  have  had  the  opportunity  of  observing  for  shorter 
periods  of  time.  "When  the  stomach  is  once  dilated  we  are  unable 
to  draw  it  together  again  like  a  tobacco-pouch,  any  more  than  an 
eccentrically  hypertrophied  heart  (excepting  the  isolated  cases  of 
acute  cardiac  dilatation)  ever  returns  to  its  normal  condition.  As 
soon  as  the  muscular  and  glandular  tissues  have  been  forced  apart 
and  infiltrated  by  an  abundant  proliferation  of  interstitial  tissue ; 
as  soon  as  the  muscular  fibers  have  undergone  fatty  or  other  degen- 
erations ;  as  soon  as  the  ducts  of  the  glands  have  been  destroyed  or 
have  undergone  cystic  degeneration — in  short,  as  soon  as  atonic 
atrophy  of  the  walls  of  the  stomach  has  appeared,  the  game  is  lost. 
Gradually  our  therapeutic  and  dietetic  measures  lose  their  efficacy, 
and  the  patients  die  of  marasmus,  and  with  more  or  less  marked 
dropsical  effusions. 

We  can  only  expect  a  decided  improvement,  or  even  a  cure  of 
the  gastric  dilatation,  when  the  process  is  in  its  earliest  stages  and 
is  produced  by  functional  disturbances,  atony,  deficient  innervation, 
or  catarrhal  conditions  of  the  mucous  membrane,  or  when  the  ob- 


298  DISEASES   OF  THE  STOMACH. 

struction  to  the  emptying  of  the  stomach  is  immediately  removed 
by  operative  procedures,  as  in  the  case  of  Klemperer.*  Korcynzski 
and  Jaworski  f  report  a  case  of  dilatation  consecutive  to  gastric 
ulcer,  in  which  the  former  disappeared  almost  entirely  and  the 
latter  was  cured  ;  they  believed  that  the  ulcer  caused  a  marked  in- 
filtration of  the  mucosa  at  the  pylorus  which  produced  a  stenosis  of 
this  orifice ;  on  the  lessening  of  the  catarrhal  condition  this  stenosis 
disappeared.  In  these  cases  the  relaxed  muscle  may  regain  its  tone 
and  the  mucous  membrane  its  normal  structure  and  function,  the 
interstitial  exudation  may  be  absorbed,  and  the  organ  in  toto 
brought  back  to  its  original  size.  It  is  very  evident  that  all  this  is 
only  possible  provided  the  anatomical  changes  have  not  exceeded  a 
definite  and  very  limited  degree ;  this  is  quite  analogous  to  the  con- 
ditions of  other  organs — the  bladder,  for  instance. 

Those  cases  of  dilatation  of  the  stomach  which  arise  from  a 
chlorotic  or  anaemic  condition,  and  which  have  been  described  as 
cured,  can  not  be  classed  with  the  true  dilatations,  as  I  have  defined 
them  above,  but  belong  to  the  group  of  gastric  insufiiciency,  which 
may  at  times  be  combined  with  a  megalogastria. 

[According  to  Boas,:{:  the  prognosis  may  be  based  upon  the  con- 
dition of  the  stomach  after  having  given  his  test  supper.  This 
consists  of  two  cups  of  tea,  two  rolls,  and  a  slice  of  cold  meat. 
This  meal  is  taken  at  8  p.  m.  On  the  following  morning  the  tube  is 
passed.  If  no  remnants  of  food  are  found  macroscopically  the 
prognosis  is  good ;  if,  on  the  contrary,  food  is  obtained,  the  case  is 
much  severer.  He  therefore  subdivides  the  cases  of  muscular  in- 
sufiiciency into  two  classes,  which  he  calls  first  and  second  degree 
respectively,  the  former  including  the  cases  of  simple  atony,  the 
latter  the  gastrectases.] 

The  prognosis  of  the  complications,  tetany,  coma  dyspepticum, 

*Klemperer.  Deutsch.  med,  Wochenschr.,  1889,  p.  170.  The  ease  was  one  of 
cicatricial  pyloric  stenosis  produced  by  corrosion  with  hydrochloric  acid ;  consecu- 
tive dilatation  of  the  stomach  (capacity,  2^  litres  [Ovss.]).  After  dilating  the  ste- 
nosis by  operation,  the  dilatation  became  less,  so  that  at  the  death  of  the  85-year- 
old  patient  two  months  later  from  phthisis,  the  stomach,  although  large,  was 
not  found  to  be  actually  dilated. 

f  Korcynzski  und  Jaworski,  Rundes  Magengeschwiir  und  saurer  Magenkatarrh. 
Deutch.  Arch,  fiir  klin.  Med.,  Bd.  xlvii,  S.  586. 

X  Boas,  op.  cit.,  Bd.  ii,  p.  70. 


TREATMENT  OF  GASTRECTASIS.  299 

etc.,  whicli  ma  J  occasionally  occur,  has  already  been  considered,  I 
merely  wish  to  add  that  several  cases  of  sudden  death  have  been 
reported  in  which  excessive  formation  of  gas  has  caused  rupture  of 
the  stomach.* 

The  treatment  f  of  dilatation  of  the  stomach  must  fulfill  two 
indications  :  1.  By  means  of  a  carefully  regulated  diet  and  appro- 
priate medication  it  must  ease  and  assist  gastric  digestion  as  much 
as  possible,  and  even  supply  nutriment  to  the  organism  in  another 
way.  2.  It  must  prevent  stagnation  of  the  stomach  contents  and 
must  expel  them  either  upward  or  downward,  and  must  also  check 
the  fermentative  processes  which  develop  in  the  stomach. 

1.  The  diet  in  dilatation  of  the  stomach  should  be  as  limited  as 
possible.  We  must  restrict  the  use  of  fluids  as  far  as  we  can ;  thin 
soups,  large  quantities  of  alcoholic  beverages,  mineral  or  other 
waters,  and  much  tea  or  coffee,  are  to  be  entirely  avoided.  I  make 
use  of  milk  even  in  only  small  quantities,  arid  give  it  in  teaspoonful 
or  tablespoonful  doses  at  frequent  intervals.  When  it  is  possible,  it 
is  advisable  to  substitute  peptonized  milk,  which  may  be  made  quite 
palatable  by  adding  cream.  Under  such  circumstances  the  most 
rational  course  to  pursue,  if  possible,  w^ould  be  to  use  Schroth's  dry 
diet  {Troc'kenhur).X  But  since  the  treatment  must  extend  not  over 
short  periods  of  time,  but  over  months,  and  even  years,  this  is  not 
applicable,  and  we  must  therefore  satisfy  ourselves  with  a  modified 
dry  diet.  The  use  of  the  peptone  preparations  is  to  be  recom- 
mended ;  for  instance,  Koch's  or  Kemmerich's  meat  peptones,  meat 
peptone  chocolate,  Maggi's  peptone  pastilles,  [Valentine's]  meat 
juice,  [somatose],  etc.,  which  contain  much  nourishment  in  a  small 
volume.*     I  have  lately  found  condensed  peptonized  milk  to  be 


*  Matthieu.  Rupture  of  the  Stomach  due  probably  to  Overdistention  by  Gases. 
Chicago  Med.  Rep.,  1887,  p.  274. 

f  [See  also  valuable  paper  by  Oser,  Wiener  Med.  Presse,  September  35,  1889. 
—Ed.] 

X  [This  very  energetic  treatment,  as  modified  by  Jiirgensen,  consists  in  giving 
the  patient  as  many  dry  rolls  as  he  wishes,  and  also  a  third  to  two  thirds  of  a  pound 
of  lean  meat  and  a  pint  of  light  claret  wine ;  no  other  fluids  are  allowed,  except  on 
every  third  or  fourth  day,  when  drinking  is  permitted.  Wet  packs  at  night.  Before 
the  cure,  fluids  are  gradually  withdrawn,  and  after  it  they  are  gradually  increased. 
The  treatment  lasis  about  a  month. — Ed.] 

*  [Analogous  preparations  are  Rudiseh's  sarcopeptones,  Carnrick's  beef  pepto- 


300  DISEASES  OF  THE  STOMACH. 

very  serviceable ;  it  has  an  agreeable  taste,  and  can  be  purchased  in 
small  packages  as  the  so-called  '■^  MuUer7nilchpatronen^^^  or  of  a 
gelatinous  consistence  in  larger  boxes.  [Ordinary  fresh  unsweetened 
condensed  milk  will  be  found  equally  useful.]  The  patients  also  like 
meat  powder,*  which  can  easily  be  made  at  home  from  dried  and 
pulverized  meat;  it  is  made  into  a  broth,  with  the  addition  of 
spices.  It  is  evident  that  all  easily  fermenting  food  stuffs,  especially 
amylaceous  foods  and  vegetables  and  fruits  which  contain  much 
sugar,  are  to  be  absolutely  avoided ;  and  it  is  only  as  a  concession  to 
the  imperative  necessity  for  starchy  foods  that  we  permit  the  patients 
to  have  a  small  quantity  of  bread,  say  Y5  to  100  grammes  [  3  ijss.  to 
iijss.]  daily — i.  e.,  two  or  three  stale  rolls  or  toast.  The  decomposi- 
tion of  the  fats  evidently  takes  place  late  and  slowly,  for  in  washing 
out  the  stomach  six  to  seven  hours  after  a  meal  we  find  the  fat 
floating  in  large  and  small  globules  on  the  surface  of  the  water,  and 
no  intense  odor  of  the  fatty  acids  is  noticeable,  which  is  always  the 
case  unless  the  stomach  is  systematically  washed  out.  However, 
since  the  fats  seem  to  exert  an  irritant  action  on  the  mucous  mem- 
brane, their  use  is  to  be  restricted  as  much  as  possible.  The 
strength  of  the  patient  may  be  kept  up  by  means  of  small  quantities 
of  strong  wine  or  strong,  unsweetened  coffee  or  tea.  ^Nutrient 
enemata  form  an  important  aid  in  nourishment ;  they  may  be  given 
in  the  form  which  I  have  spoken  of,  or  as  suppositories  of  peptone, 
the  use  of  which  can  be  continued  for  weeks  or  months.  By  such 
means  nourishment  by  the  mouth  may  be  reduced  to  a  minimum 
for  days — i.  e.,  until  the  condition  of  gastric  digestion  has  been  im- 
proved as  much  as  possible ;  enemata  also  possess  the  advantage  of 
preventing  the  lack  of  water  in  the  tissues  by  means  of  the  fluids 
introduced  (Liebermeister). 

2.  Hydrochloric  acid  in  large  doses  is  an  excellent  remedy  for  all 
gastric  dilatations  which  are  not  dependent  upon  pure  atony  of  the 
muscle.  We  may  commence  with  ten  to  fifteen  drops  of  dilute  hy- 
drochloric acid,  taken  through  a  glass  tube  in  a  tablespoonf  ul  of 
water  every  hour.    Concerning  the  other  disinfectants,  I  would  refer 

noids,  Bush's  bovinine,  etc.  Peptone  chocolate  is  now  sold  in  this  country  under 
the  name  of  vigor  chocolate. — Ed.] 

*  [Mosquera's  beef  meal  may  be  used  for  this  purpose. — Ed.] 


TREATMENT  OP  GASTllECTASIS.  301 

to  wliat  has  already  been  said  on  page  233.  Kuhn  (hoc.  cit.)  lias 
tabulated  the  various  useful  antifermentatives  according  to  their 
value  in  checking  fermentation,  the  percentages  denoting  the  con- 
centration necessary  for  this  purpose  : 

Acid,  salicylic. .   0-0025  per  cent,  Kesorcin . .   0-25  per  cent. 

Natriisalicylas.   0-0025       "  Creosote..   0-5         " 

Natrii  benzoas .   0-03  "  Acid,  boric,  over  1  " 

Saccharin 0-05  "  Aq.  chlori.   5  " 

Acid,  carbohc. .   0-1  "  Alcohol ...   5  p.  c.  or  more. 

If  carcinoma  of  the  stomach  exists,  it  is  best  to  use  a  maceration 

of  condurango,  with  the  proper  quantity  of  hydrochloric  acid.     In 

case  there  is  much  pain  in  the  stomach,  I  make  use  of  the  sedative 

and  antiseptic  action  of  chloral,  combined  with  cocaine,  as  follows  : 

]^   Cocain.  hydrochlor 0-3  [gr.  jvss.] 

Chloral,  hydrat 3-0  [gr.  xlv] 

Aq.  menth.  pip 50-0  [f  ^  jf ] 

Aq 100-0  [f^iiji] 

M.  Sig. :  Tablespoonful  every  two  hours. 
Dujardin-Beaumetz  speaks  highly  of  introducing  large  doses  of 
bismuth,  50  grammes,  suspended  in  500  c.  c.  of  water  [  ^  jss.  bis- 
muth to  O  j  water],  from  which  the  drug  is  said  to  be  deposited  on 
the  gastric  mucous  membrane  ;  *  injections  of  morphine  are  eventu- 
ally unavoidable. 

Atonic  conditions  of  the  muscle  require  the  exhibition  of  strych- 
nine, as  extract  or  tincture  of  nux  vomica,  which  had  been  formerly 
recommended  by  Skjelderup  and  Duplay,t  who  did  not  draw  this 
sharp  distinction.  It  can  be  given  without  bad  effects  in  large  doses 
— 0-1  to  0-15  [gr.  jss.-ij:^]  !  of  the  extract  pro  die.  Dr.  "Wolff  has 
proved  at  my  clinic  that  it  also  increases  the  production  of  hydro- 
chloric acid. 

The  cathartics  and  drastics  have  always  played  an  important 
part  in  the  therapy  of  gastric  dilatation  ;  they  are  really  of  service, 
probably  by  sympathetic  stimulation  of  the  gastric  peristalsis,  not 
only  in  evacuating  the  intestines  but  the  stomach  as  well,  as  soon 
as  they  have  passed  the  pylorus,  or,  indeed,  have  been  absorbed  at 

*  Bullet,  gener.  de  therapeutique,  1883,  No.  1. 
f  Arch,  gener.  de  med.,  Nov.,  Dec,  1883. 


302  DISEASES  OF  THE  STOMACH. 

all,  neither  of  which  is  always  the  case.  Penzoldt  was  able  to 
directly  prove  the  beneficial  effect  of  Carlsbad  salts  in  lessening  the 
quantity  of  the  stomach  contents,  for  the  quantity  removed  from  the 
organ  while  the  salts  were  used  amounted  to  850  c.  c.  [f  ^  xxviij], 
while  without  them,  the  condition  being  otherwise  the  same,  they 
measured  1,525  c.  c.  [3|^  pints].  Kussmaul  recommends  drastic  pills, 
composed  of 

^  Extr.  colocynth.  spirit.  (G.  P.) 0-5  [gr.  vijss.] 

Extr.  rhei  comp.  (G.  P.), 

Sive 

Extr.  aloes  aquos., 

Extr.  scammon aa  2-0  [gr.  xxx] 

M.     Div.  in  pil.  no.  xxx. 
Sig.  :  One  pill  before  dinner. 
I  have  frequently  used  aloin  subcutaneously  with  good  results. 

3.  To  meet  the  second  of  the  two  indications  given  above,  lav- 
age, the  sovereign  remedy  in  the  treatment  of  dilatation,  is  to  be 
used.  1  will  disregard  the  many  appliances  devised  for  this  pur- 
pose, because,  to  my  mind,  they  are  like  carrying  coals  to  ]!^ewcastle. 
The  use  of  the  stomach  tube,  with  a  funnel  attached  to  it,  and  the 
cleansing  of  the  stomach  by  the  alternate  introduction  and  removal 
of  large  quantities  of  water,  is  the  simplest  and  at  the  same  time 
an  entirely  efficient  method.  We  must  not  stop  until  the  water 
returns  clear  or  only  very  slightly  turbid,  but  by  all  means  entirely 
free  from  fragments  of  food  and  flakes  of  mucus.  At  times, 
toward  the  end  ®f  the  operation,  after  the  water  has  come  back  clear 
for  some  time,  it  suddenly  becomes  turbid  again  from  the  presence 
of  large  masses  of  stomach  contents ;  this  occurs  especially  when 
there  are  well-marked  pouches  in  the  stomach,  the  contents  of  which 
are  only  stirred  up  toward  the  last  by  the  entrance  of  the  water  or 
the  bearing  down  of  the  patient.  We  must  allow  all  the  time  we 
can  for  the  possible  digestion  of  the  food  which  may  be  in  the  stom- 
ach, and  therefore  we  must  only  empty  the  stomach  when  large  ac- 
cumulations are  present — i.  e.,  to  wash  out  only  six  or  seven  hours 
after  the  principal  meal.  Besides  the  actual  washing  out  which  is 
to  prevent  the  mechanical  overloading  of  the  stomach,  we  conclude 
the  operation  with  irrigation  of  the  mucous  membrane  with  antisep- 


TREATMENT  OF   GASTRECTASIS.  303 

tic  or  antifermentative  solutions.  In  cases  of  very  marked  fermen- 
tation we  can  clean  the  "vralls  of  the  stomach  more  quickly  and  thor- 
ouo-hly  by  washing  out  the  stomach  in  the  morning  before  breakfast 
when  the  viscus  is  empty,  as  ISTaunyn  and  Minkowski  have  also  ad- 
vised. I  have  had  patients  in  whom  the  morning  lavage  produced 
much  better  results  than  that  done  in  the  evening.  Still  the  time 
must  be  adapted  to  the  individual  case.  Thus  in  continuous  hyper- 
secretion it  is  better  to  wash  the  stomach  in  the  evening,  or  even 
both  morning  and  evening.  As  antiseptics  we  may  use  solutions  of 
salicylic  acid  0-3  to  0-5  per  cent,  or  borax  2  to  4  per  cent  (dissolved 
in  hot  water),  or  sodium  subsulphate  10  to  20  per  cent,  as  well  as  a 
great  number  of  other  disinfectants,  such  as  naphthalin,  resorcin, 
benzoic  acid,  permanganate  of  potash,  etc.  These  substances,  the 
efficacy  of  which  is  well  known,  should  suffice. 

The  advantages  which  accrue  from  this  procedure  are  so  appar- 
ent that  it  is  really  incomprehensible  why  this  method  should  not 
have  been  introduced  earlier  into  therapeutics.  To  avoid  repetitions 
I  shall  not  add  anything  further  on  the  benefits  of  lavage  of  the 
stomach,  for  its  manifold  advantages  can  readily  be  recognized. 
However,  of  one  of  these  I  must  speak,  for  it  appears  very  fre- 
quently, if  not  always — namely,  the  effect  on  the  stools.  Many 
patients  who  have  had  to  contend  with  habitual  constipation  through- 
out the  whole  course  of  their  illness  have  had  free  passages  after  the 
washings,  especially  at  the  commencement  of  the  treatment.  Kuss- 
maul,*  who  has  called  attention  to  this  effect  of  lavage,  always  con- 
siders its  absence  an  ominous  sign  ;  in  other  words,  he  believes  that 
the  persistence  of  obstinate  constipation  always  indicates  an  irrepar- 
able disorganization  of  the  stomach  and  an  incurable  stenosis  of  the 
pylorus.  But  this  much  is  certain,  that  in  scarcely  any  other  jplace 
in  the  lohole  range  of  the  therapy  of  diseases  of  the  stomacli  can  we 
attain  such  hrilliant  results  as  we  can  in  the  treatment  of  a  case  of 
protracted  dilatation  of  the  stomach.  The  disgusting  vomiting,  the 
feeling  of  fullness,  the  eructations,  the  dyspeptic  difficulties,  and  the 
cerebral  symptoms  either  cease  entirely  or  become  markedly  im- 
proved.    Consequently  lavage  is  being  employed  more  and  more,  so 

*  Loc.  cit.,  p.  467. 


304  DISEASES  OP  THE  STOMACH. 

that  the  severe  and  neglected  cases  of  dilatation  which  were  for- 
merly encountered  are  now  no  longer  seen. 

How  often  shall  we  wash  out  the  stomach  ?  Daily,  or  at  longer 
intervals,  or  as  often  as  several  times  a  day  ?  I  consider  daily  wash- 
ings at  the  time  specified  to  be  indispensable.  But  they  must  be 
conscientiously  continued  for  a  long  time — the  patients  soon  learn 
to  do  it  themselves — and  we  must  not  be  guided  alone  by  the  sub- 
jective sensations  of  the  patient.  Should  the  latter's  apparently 
good  condition  induce  us  to  allow  longer  intervals  to  intervene,  so- 
called  relapses  are  sure  to  occur,  since  stagnation  and  its  conse- 
quences will  always  return.  The  present  technique  is  so  simple  and 
safe  that  less  can  be  said  against  it  than,  for  instance,  against  long- 
continued  catheterization  in  hypertrophy  of  the  prostate.  I  have 
as  yet  never  seen  any  unpleasant  accidents  occurring  after  lavage  ; 
yet  Fenwick  *  has  collected  a  number  of  cases  which  have  been  re- 
ported, and  from  his  own  practice  (seven  cases  in  all),  in  which  per- 
foration, haemorrhage,  convulsions,  and  death  after  various  intervals 
occurred  after  lavage.  However,  a  number  of  these  cases  should 
never  have  been  washed  out,  or  the  same  thing  may  have  happened 
here  as  occurred  in  a  case  reported  by  Martin,t  in  which  death  sud- 
denly occurred  six  hours  after  a  tube  had  been  introduced  into  a 
dilated  stomach  with  stricture  of  the  pylorus,  ^o  injury  of  the 
viscus  was  found  at  the  autopsy,  and,  since  sudden  collapse  and 
death  may  occasionally  occur  in  cases  of  cancer  without  any  cause 
at  all,  it  appears  to  me  that  this  was  simply  a  coincidence.  [An  in- 
teresting fact  concerning  the  great  value  of  lavage,  etc.,  in  gastrec- 
tasis  is  the  statement  of  Kussmaul,  that  in  the  last  ten  years  he  has 
not  seen  a  single  case  of  tetany,  although  he  was  the  first  to  describe 
it  as  a  complication  of  this  condition,  ij:  ] 

Here  we  must  also  mention  the  few  cases  in  which  rupture  of  the 
gastric  mucosa  or  wall  has  occurred  (usually  longitudinally  along 
the  lesser  curvature)  as  the  result  of  overloading  the  stomach  with 
fluids.     A.  Key- Aberg  *  has  carefully  reported  a  case  of  this  kind 


*  Loc.  cit.,  on  p.  15. 

f  Martin.     Death  after  washing  out  Dilated  Stomach.     Lancet,  1887,  No.  2. 
X  [Quoted  by  Fleiner.     Loc.  cit,  p.  254.— Ed.] 

*  A.  Key- Aberg.     Vierteljahrschr.  fiir  gerichtlich.  Med.  und  offentl,  Gesund- 
heitspflege,  3te  Folge,  Bd.  1,  1891. 


TREATMENT  OF   GASTRECTASIS,  305 

in  wliicli  rupture  of  gastric  mucosa  and  hsemorrliage  were  caused  by 
the  water  left  in  tlie  stomach  after  lavage  in  a  case  of  opium  poison- 
ing ;  the  man,  altliough  semiconscious,  nevertheless  retched  a  great 
deal.  He  also  cites  the  few  cases  of  this  kind  which  have  been  re- 
ported, some  of  which  are  not  entirely  free  from  objections.*  Other 
details  on  the  complications  of  lavage  have  already  been  discussed 
on  page  15. 

Massage  and  faradization  of  the  stomach  I  consider  adjuvants 
of  lavage.  The  former,  if  intelligently  applied,  forces  the  contents 
of  the  stomach  into  the  intestines,  and  in  this  way  dilates  the  py- 
lorus by  means  of  mechanical  pressure.  Yet  we  must  avoid  forcing 
masses  into  the  duodenum  which  are  too  acid  or  too  acrid,  which 
can  not  be  sufficiently  neutralized  by  the  intestinal  juices,  and  which 
produce  conditions  of  irritation  in  the  mucous  membrane  of  the 
intestine.  Zabludowski,t  of  Gerhardt's  clinic,  has  published  very 
good  results  from  the  use  of  massage  in  dilatation  of  the  stomach, 
together  with  an  exact  account  of  the  technique  employed.  On  the 
other  hand,  we  must  not  forget  that  the  decided  pressure  exerted  on 
the  stomach  will  distend  and  dilate  the  gastric  walls  if  the  chyme  is 
not  forced  through  the  pylorus. 

Faradization  of  the  stomach  has  already  been  discussed  on  page 
102.  It  certainly  accelerates  the  emptying  of  the  stomach.  For  ex- 
ample, Brunner  %  demonstrated  that  a  test  breakfast  disappeared 
much  more  rapidly  from  the  stomach  when  the  abdominal  walls 
were  faradized.  I  have  so  often  convinced  myself  of  the  beneficial 
effects  of  intragastric  faradization,  and  the  patients  themselves  have 
so  decidedly  felt  that  it  alone  benefited  them  (for  they  lost  ground 
as  soon  as  it  was  discontinued),  that  I  am  sure  that  the  results  are 
due  to  something  more  than  suggestion. 

Cold  douches  and  applications  are  said  to  have  a  tonic  effect 
upon  the  muscle  fibers  of  the  stomach,  as  well  as  the  so-called  Scotch 
douche,  as  recommended  by  Winternitz  and  Baum.* 

*  Revilliod.    Rupture  de  restomac.   Rev.  med.  de  la  Suisse  Romande,  1855,  No.  1. 
f  Zabludowski.     Zur   Massagetherapie.     Berliner   klin.  Wochenschrift,    1886, 

S.  443. 

X  W.  Brunner.  Zur  Diagnostik  der  motorischen  Insul!icienz  des  Magens. 
Deutsche  med.  Woehenschr.,  1889,  No.  7. 

*  Wiener  med.  Presse,  1873,  No.  17.     ["  This  consists  of  a  stream  of  water,  the 


306  DISEASES  OF  THE  STOMACH. 

In  a  few  cases  of  marked  dilatation  I  liave  obtained  good  results 
from  wearing  an  abdominal  bandage  (as  will  be  described  more  fully 
under  Gastroptosis),  since  the  relaxed  abdominal  walls  are  supported 
and  thus  facilitate  the  movements  of  the  stomach  and  intestines. 

Surgical  Treatment. — Finally,  we  must  think  of  dilatation  or  ex- 
cision of  the  steatosis.  I  can  not  do  much  more  than  mention  these 
procedures  here,  and  therefore  simply  call  attention  to  the  fact  that 
quite  a  series  of  successful  operations— i.  e.,  excision  of  the  con- 
stricting tumor,  forcible  dilatation  of  the  cicatricial  stenosis,  and  gas- 
troenterostomy— has  been  published  during  the  past  few  years.  Thus, 
Hubert  describes  two  cases  of  forcible  digital  dilatation  of  cicatricial 
stenosis  of  the  pylorus  which  were  operated  upon  by  Prof.  Loreta 
in  Bologna,  and  apparently  were  radically  cured.*  A  method 
which  is  worthy  of  special  consideration  is  that  proposed  by  Hei- 
necke  and  Mikulicz,  of  splitting  the  stricture  longitudinally  and  then 
passing  the  sutures  transversely  ;  a  number  of  excellent  results  have 
been  obtained  by  this  operation. 

The  question  of  whether  resection  of  the  pylorus  or  gastroenter- 
ostomy is  preferable  has  been  carefully  discussed  during  the  past 
few  years  by  many  eminent  surgeons,  of  whom  I  shall  mention  only 
the  German  operators,  Billroth,  Liicke,  Mikulicz,  Hahn,  Lauenstein, 
Yon  Hacker,  etc.  The  indications  and  technique  have  been  much 
improved.f  Thus,  for  example,  Lauenstein  X  reports  IT  cases  of 
gastroenterostomy,  in  13  of  which  there  was  cancer  of  the  pylorus. 
Five  cases  were  fatal  and  12  were  successful  so  far  as  the  operation 
was  concerned.  Three  of  the  cases  which  were  operated  on  account 
of  benign  stenosis  remained  permanently  well.  Of  the  13  operated 
because  of  pyloric  cancer,  three  died  ;  the  others  survived  on  an  aver- 

size  of  a  finger,  which  is  directed  against  the  region  of  the  stomach.  The  tempera- 
ture of  the  water  changes  every  twenty  seconds  between  80°  and  50°  Fahr.  (26°  and 
10°  C),  and  is  continued  for  three  minutes."  Decker,  Munch,  med.  Wochen.,  May 
28,  1889.— Ed.] 

■'■  Hubert.  Jour,  de  med.  de  Bruxelles,  avril,  1883,  p.  309.  [Also  Loreta, 
Lancet,  April  26,  1884;  Bull  and  Kinnicutt,  A  Case  of  Cicatricial  Stenosis  of 
Pylorus  relieved  by  Loreta's  Operation.  New  York  Medical  Record,  June  8,  1889. 
This  paper  gives  the  results  of  twenty  cases. — Ed.] 

f  An  exhaustive  discussion  may  be  found  in  the  dissertation  of  W.  Hellwig. 
Behandlung  der  Magenerweiterung  mit  Gastroenterostomie.     Halle,  1892. 

X  C.  Lauenstein.  Zur  Indication,  Anlegung  und  Function  der  Magendiiradarm- 
fistel.     Centralbl.  fur  Chirurgie,  1891,  No.  40. 


TREATMENT  OP  GASTRECTASIS.  307 

age  five  montlis,  and  were  free  from  symptoms  for  about  three 
months.  Hahn's  *  results  are  still  better :  11  operations,  of  which 
6  were  fatal ;  one  case  survived  5  years  (!),  another  one  year,  the 
others  survived  several  months.  Hellwig  f  reports  two  successful 
cases  which  had  been  operated  on  by  von  Bramann,  and  summarizes 
the  operative  indications  as  follows  :  "  Gastroenterostomy  is  gener- 
ally indicated  in  those  cases  of  dilatation  of  the  stomach  in  which 
a  demonstrable  obstruction  exists  at  the  pylorus  which  can  not  be 
removed  by  a  radical  operation ;  otherwise  resection  of  the  pylorus 
ought  to  be  performed.  However,  the  general  condition  of  the 
patient  ought  to  be  at  least  such  that  there  should  be  no  metastases, 
and  the  possible  duration  of  life  should  not  be  one  of  a  few  months." 

Yon  Bramann  urges  that  gastroenterostomy  ought  also  to  be  per- 
formed on  severe,  primary  gastrectases  to  spare  the  patients  the 
years  of  lavage.  Birchner,;}:  on  the  other  hand,  suggests  making  a 
fold  in  the  walls  of  the  stomach  so  as  to  elevate  the  greater  curva- 
ture, thereby  raising  the  lowest  part  of  the  stomach  to  such  a  level 
that  the  contractions  of  the  stomach  may  expel  the  chyme  through 
the  pylorus.  This  is  a  less  serious  operation  than  gastroenterostomy, 
and  Birchner  has  already  reported  thi-ee  successful  cases.  Although 
in  the  second  edition  of  this  book  I  have  already  suggested  a  similar 
procedure — i.  e.,  to  excise  a  lancet-shaped  piece  of  the  wall  of  the 
stomach — yet  Birchner's  operation  will  probably  only  be  successful 
in  those  cases  in  which  the  pyloric  obstruction  is  not  such  that  a 
fresh  dilatation  will  be  formed  later  on.  Furthermore,  it  is  very 
much  to  be  feared  in  this  and  similar  operations  that  the  patients 
may  subsequently  be  troubled  by  the  resulting  cicatrices. 

It  is  not  my  province  to  enter  into  further  details  of  this  topic. 
Enough  has  been  said  to  show  that  surgeons  are  ready  to  afford 

*  E.  Hahn.  Ueber  Gastroenterostomie.  Deutsch.  med.  Wochensehr.,  1891, 
No.  30. 

f  Hellwig,  loc.  cit. 

X  Birchner.  Eine  operative  Behandlung  der  Magenerweiterung.  Correspon- 
denzbl.  fur  schweizer  Aerzte,  1891,  No.  23.  [Weir.  New  York  Medical  Journal, 
July,  1892.  Up  to  1894  this  operation  had  been  performed  seven  times;  all  recov- 
ered promptly.  In  five  there  was  complete  restoration  of  the  stomach,  one  died 
after  a  second  operation  ;  cancer  was  suspected  in  this  case  ;  another  case  died  from 
heart  failure  six  weeks  after  the  operation.  Quoted  from  American  Yearbook  of 
Medicine  and  Surgery,  1896,  p.  124.— Ed.] 


308  DISEASES  OF  THE  STOMACH. 

relief  where  our  former  methods  left  us  in  the  lurch,  and  that  it  is 
our  duty  in  every  case  of  this  kind  to  consider  as  early  as  possible 
the  possibilities  of  operative  relief.  Jaworski,  Obalinski,  and  Rydy- 
gier  *  have,  however,  shown  what  was  to  have  been  expected  apriori, 
that  in  cancer  of  the  stomach,  even  when  these  operations  of  resec- 
tion and  gastroenterostomy  are  successful,  neither  the  mechanical 
nor  the  chemical  functions  of  the  stomach  return  to  the  normal,  but 
that  in  general  only  symptomatic  relief  is  afforded  by  the  removal  of 
the  mechanical  obstruction.  Nevertheless,  in  these  cases  decided 
subjective  and  objective  relief  is  obtained,  in  spite  of  the  fact  that 
the  presence  of  a  malignant  cicatrization  in  the  stomach  must  also 
exert  a  deleterious  effect  on  the  functions  of  the  intestines,  liver, 
and  pancreas.  Thus  in  Jaworski's  case  the  stools  were  frequent, 
soft,  and  decolorized,  and  also  contained  much  undigested  meat  and 
fat ;  biliary  coloring  matter  was  also  absent. 

So  far  as  I  may  judge  from  my  own  cases — four  of  resection  of 
the  pylorus  and  three  gastroenterostomies — I  would  only  advise  re- 
section in  nonmalignant  stenoses ;  in  all  other  cases,  gastroenteros- 
tomy. For,  no  matter  how  sharply  a  cancer  may  seem  to  be  limited 
macroscopically,  there  are  always  numerous  offshoots  which  often 
extend  a  considerable  distance;  hence,  "operating  in  the  healthy 
tissues "  is  usually  only  a  delusion  (see  chapter  on  Cancer  of  the 
Stomach).  Senn,  one  of  the  most  distinguished  surgeons  in  this 
branch,  closes  an  exhaustive  study,f  in  which  he  reports  13  gastro- 
enterostomies, with  8  so-called  cures — i.  e.,  death  weeks  or  months 
after  the  operation — as  follows  : 

"  1.  Pyloroplasty,  as  devised  by  Heinecke-Mikulicz,  is  the  safest 
and  most  efficient  operation  for  cicatricial  stenosis  of  the  pylorus. 

"  2.  Pylorectomy  in  the  treatment  of  carcinoma  of  the  pylorus  is 
a  justifiable  procedure  when  the  disease  is  limited  to  the  organ 
primarily  affected  and  the  patient's  general  condition  furnishes  no 
contraindication. 

"  3.  Gastroenterostomy  by  the  aid  of  large,  moist,  perforated 

*  Jaworski  und  Obalinski.  Wiener  klin.  Wochensehr.,  1889,  No.  5. — Jaworski 
und  Rydygier.     Deutsch.  med.  Wochensehr.,  1889,  No.  14. 

t  Senn.  The  Surgical  Treatment  of  Pyloric  Stenosis,  with  a  Report  of  Fifteen 
Operations  for  this  Condition.  New  York  Medical  Record,  November  7  and  14, 
1891. 


imm 


TREATMENT  OF  GASTRECTASIS.  309 

plates  of  decalcified  bone  should  be  resorted  to  in  the  treatment  of 
malignant  stenosis  of  the  pylorus  as  soon  as  a  positive  diagnosis 
can  be  made,  and  a  radical  ojDeration  is  contraindicated  by  local  or 
general  conditions  of  the  patient." 

[The  present  view  as  to  the  surgical  treatment  of  dilatation  due 
to  pyloric  stenoses,  either  benign  or  malignant,  is  decidedly  in  favor 
of  gastroenterostomy.  Thus  Eosenheim  *  reports  8  cases  which 
were  operated  in  this  way  with  no  deaths,  the  improvement  in  the 
gastric  functions  being  satisfactory  in  all  of  them.  Loreta's  opera- 
tion has  fallen  into  disfavor;  pyloroplasty  and  resection  of  the 
pylorus  have  still  a  high  mortality,  that  of  the  former  being  22*6 
per  cent.,  according  to  Mintz  (see  also  Surgical  Treatment  of  Cancer 
of  Stomach).  The  use  of  the  Murphy  button  has  not  materially 
changed  these  indications. 

According  to  Fleiner,f  ojDerative  interference  is  indicated  when 
the  amounts  of  food  and  fluid  which  pass  from  the  stomach  into  the 
intestines  no  longer  suffice  for  the  needs  of  the  system,  and  when 
these  factors  and  the  disturbances  of  the  economy  which  result 
from  the  lesion  can  not  be  remedied  by  medical  treatment.  Well- 
marked  tetany  is  a  contraindication  to  operative  interference  ;  still, 
if  the  tetany  can  be  improved  by  appropriate  treatment,  an  operation 
may  be  attempted.  One  of  the  four  cases  which  he  reports  was 
successful.] 

I  shall  now  apply  the  foregoing  remarks  to  some  practical  ex- 
amples ;  for  this  purpose  I  have  not  selected  hospital  cases,  with  the 
results  of  autopsies,  but  such  patients  as  we  meet  in  daily  practice : 

The  first  patient  is  a  railroad  secretary,  fifty-two  years  of  age,  whose 
previous  history  I  shall  give  in  his  own  words : 

"  Ten  months  ago,  in  the  beginning  of  last  year,  I  was  taken  sick  with 
loss  of  appetite,  constipation,  slight  malaise,  and  also  a  cough,  with  expec- 
toration. On  the  14th  of  June,  a  year  ago,  I  went  to  Gorbersdorf,  in 
Silesia,  at  the  advice  of  my  physician,  and  remained  there  under  treat- 
ment, at  the  institute  of  Dr.  Rompler,  until  July  10th.  On  July  10th  I 
went  to  Carlsbad,  where  the  diagnosis  of  dilatation  of  the  stomach  was 
made.     I  was  treated  there  till  August  14th  (five  weeks)  ;  the  physician 

*  [Rosenheim,  op.  cit.,  p.  485.    An  excellent  resume  of  this  subject  may  be  found 
here  and  in  Boas,  op.  cit.,  Bd.  ii,  p.  122. — Ed.] 
t  [Fleiner,  loc.  cit.,  p.  262.— Ed.] 


310  DISEASES  OP  THE  STOMACH. 

told  me  tliat  I  was  at  the  proper  spring.  At  Carlsbad  I  drank  three  half- 
glasses  of  Schlossbrunnen  daily,  and  besides  took  four  Sprudel  and  eight 
rai;d  baths  (one  every  third  day).  The  action  of  the  baths  was  always 
sedative  for  several  hours.  In  general  the  treatment  at  Carlsbad  aflPected 
my  body  quite  unfavorably,  my  strength  was  not  correspondingly  in- 
creased, and  a  slow,  improvement  could  only  be  observed  at  intervals  of 
from  four  to  five  weeks.  After  the  10th  of  August  I  was  under  the  treat- 
ment of  another  physician.' 

When  I  first  examined  this  patient,  who  was  sent  to  me  by  his  family 
physician  on  the  24th  of  October,  although  he  was  thin,  he  by  no  means 
looked  sick.  Lungs  and  heart  normal ;  liver  not  enlarged  ;  its  lower  edge 
can  be  felt  distinctly  a  finger's  breadth  below  the  free  margin  of  the  ribs. 
Spleen  not  enlarged ;  the  stomach,  however,  showed  the  following  changes : 
Even  on  mere  inspection  of  the  abdomen,  and  especially  on  looking  at  it 
against  the  light,  with  the  patient  lying  down,  I  can  see  a  slight  protuber- 
ance the  size  of  a  five-mark  piece  [about  the  same  as  a  silver  dollar]  in  the 
region  of  the  umbilicus,  and  extending  to  the  right ;  it  projects  so  slightly 
above  the  surface  of  the  abdomen  that  it  is  only  recognizable  by  the  relief 
given  by  its  shadow.  Otherwise  the  abdominal  walls  are  smooth,  not  too 
relaxed,  with  neither  troughlike  depression  nor  abnormal  vaulted  projec- 
tion. Palpation  reveals  a  tumor  at  the  place  mentioned,  about  the  size  of 
an  apple,  hard,  nodular,  easily  movable,  which  does  not  descend  on  res- 
piration, and  entirely  insensitive  to  pressure.  Tapottement  produces  loud 
succussion  sounds.  No  slapping  sounds  (Klatschgerdusch).  The  inguinal 
glands  are  about  the  size  of  a  pea,  but  there  are  no  other  adenopathies. 
The  patient  has  taken  a  test  breakfast.  I  introduce  the  stomach  tube, 
and  on  expression  obtain  about  100  c.  c.  [  |  iij^]  of  a  thin  fluid,  which  con- 
tains some  remnants  of  the  roll.  I  now  inflate  the  stomach  with  the  double 
bulb,  and  you  can  see  that  the  tumor  is  displaced  somewhat  to  the  right 
and  downward,  and  that  the  contour  of  the  stomach  becomes  very  distinct. 
By  sight  alone,  but  better  by  means  of  percussion,  I  can  locate  the  greater 
curvature  3  centimetres  [1|  inch]  below  the  timbilicus.  Examination  of 
the  stomach  contents,  which  have  been  filtered,  reveals  the  total  ab- 
sence of  hydrochloric  acid,  faint  peptone  reaction,  large  amounts  of  pro- 
peptone,  erythrodextrin,  fatty  acids,  but  no  lactic  acid.  At  a  former  ex- 
amination I  ascertained  that  the  filtrate  of  the  stomach  contents  did  not 
digest  albumen,  and  from  the  examination  made  six  hours,  after  a  dinner 
consisting  of  meat,  potatoes,  bread,  and  bouillon  the  same  results  were  ob- 
tained. Neither  yeast  cells,  sarcinse,  nor  cancerous  elements  are  present. 
The  patient  took  1  gramme  [gr.  xv]  of  salol  yesterday,  and  has  brought 
the  urine  voided  three  quarters  of  an  hour,  an  hour  and  a  quarter,  and  an 
hour  and  three  quarters  afterward.  In  the  last  portion  we  get  an  indis- 
tinct violet  coloration  on  adding  ferric  chloride,  but  I  must  first  shake 
up  the  urine  with  ether  in  order  to  obtain  a  positive  though  only  a  weak 
reaction. 

In  view  of  all  this  there  can  be  no  doubt  that  the  diagnosis  is  cancer- 
ous stenosis  of  the  pylorus,  with  consecutive  dilatation  of  the  stomach. 
It  is  interesting  that  in  this  case  the  disease  began  so  insidiously,  and  that 
it  pointed  so  little  to  the  stomach  as  its  seat,  that  probably,  in  connection 
with  a  then-existing  bronchial  catarrh,  the  suspicion  of  phthisis  could 


CASES   OF   GASTRECTASIS.  311 

arise,  which  led  to  his  being  sent  to  Gorbersdorf.  I  have  seen  excellent 
results  in  the  treatment  of  phthisis  in  Gorbersdorf,  but  carcinomata  can 
not  also  be  cured  there  !  The  case  is  so  far  a  favorable  one  in  that,  on  the 
one  hand,  the  bodily  strength  is  relatively  good,  and,  on  the  other,  the 
tendency  to  decomposition  of  the  stomach  contents  is  comparatively  slight. 
In  the  way  of  treatment  the  patient  has  been  taking  condurango,  with 
hydrochloric  acid,  and  for  the  past  week  his  stomach  has  been  washed  out 
regularly  every  second  evening,  six  hours  after  his  dinner  ;  considerable 
quantities  of  stomach  contents,  brown  in  color,  have  always  been  brought 
up.  I  proposed  to  the  patient  to  have  the  tumor  excised,  which,  according 
to  competent  authority,  can  be  done  in  this  case.  However,  he  feels  so 
much  easier  and  better  under  the  present  treatment  that  he  can  not  decide 
upon  having  it  done,  and  thus,  as  is  alas  so  frequent,  the  favorable  moment 
for  undertaking  it  will  pass  by. 

The  second  case,  which  I  will  deal  with  at  less  length,  concerns  a  fifty- 
two-year-old,  large,  strongly  built,  somewhat  pale  woman.  For  about  a 
year  and  a  half  she  has  suffered  severely  with  acid  eructations.  To  this 
has  been  added  a  constant  loss  of  appetite,  and  partly  owing  to  this,  partly 
because  she  has  kept  a  strict  diet,  her  nutrition  has  suffered  considerably. 
No  difiiculties  in  swallowing.  Vomiting  has  been  very  infrequent,  lately 
every  fortnight,  and  is  said  to  have  consisted  of  very  sour,  slimy  masses, 
mixed  with  but  slightly  changed  remnants  of  food  ;  blood  has  never  been 
present.  Stools  hard  and  sluggish.  The  urine  has  been  repeatedly  exam- 
ined, with  negative  result.  The  patient  was  formerly  very  healthy,  vigor- 
ous, and  active  about  the  house,  and  has  borne  nine  children.  Although  I 
pass  over  the  examination  of  the  other  organs,  in  which  there  is  nothing 
abnormal,  I  wish  to  call  attention  to  the  relaxed  condition  and  markedly 
vaulted  projection  of  the  abdominal  walls,  on  which  I  can  at  once  pro- 
duce loud  succussion  sounds.  I  can  not  palpate  a  tumor  anywhere,  yet  I 
feel  the  pulsations  of  the  aorta.  The  patient  "  expresses  "  a  light-brown 
fluid — she  had  some  meat  and  coffee  four  hours  ago ;  on  inflation  with 
air  the  entire  abdominal  cavity  immediately  becomes  evenly  distended,  so 
that  we  can  see  the  lower  border  of  the  stomach  running  just  above  the 
symphysis ;  the  whole  abdomen  appears  like  an  evenly  inflated  balloon. 
The  salol  test  does  not  show  any  retardation.  The  filtrate  of  the  stomach 
contents  has  an  acidity  of  48  per  cent  with  a  decinormal  soda  solution, 
and  distinctly  contains  free  hydrochloric  acid,  peptone ;  only  traces  of 
propeptone  ;  it  also  digests  well.    Lactic  acid  is  present  in  small  quantities. 

The  diagnosis  of  gastric  dilatation,  which  can  not  be  doubted,  does 
not  seem  to  have  been  made  before.  The  question  arises.  To  what  can 
the  dilatation  be  referred  ?  A  previous  ulcer  may  be  rejected  with  great 
probability  on  account  of  the  absence  of  pain,  and  altogether  on  account 
of  the  previous  good  general  condition.  Thus,  also,  tumors  of  any  kind 
whatsoever  may  be  excluded,  and,  granted  that  further  observations  yield 
no  results  different  from  to-day's,  we  can  only  have  to  deal  with  a  cica- 
tricial distortion  or  adhesion,  or  with  a  primary  atony  of  the  gastric  mus- 
cular fibers.  Even  though  the  former  could  be  a  result  of  puerperal  peri- 
tonitis which  had  run  a  latent  course,  yet  this  is  only  to  be  surmised.  At 
any  rate,  the  prognosis  is  favorable  for  improvement  within  a  short  time 
in  view  of  the  presence  of  free  hydrochloric  acid. 
21 


312  DISEASES  OP  THE  STOMACH. 

I  persuaded  the  patient,  who  had  come  from  a  distance,  to  enter  the 
sanitarium,  where  she  could  be  treated  with  an  appropriate  dry  diet,  sys- 
tematic lavage,  strychnine,  and  faradization  of  the  stomach. 

Three  weeks  after  the  treatment  had  been  begun,  HCl  disappeared 
permanently,  and  a  small  tumor,  hardly  the  size  of  a  walnut,  was  discov- 
ered in  the  pyloric  region.  Operation  was  proposed  but  was  rejected  by 
the  patient,  who  left  the  sanitarium  and  died  a  few  months  later  of  cancer 
of  the  stomach. 

(I  wish  to  direct  particular  attention  to  this  case,  because  it  is  typical 
of  its  kind.  To-day  I  would  be  still  more  guarded  in  the  diagnosis  and 
prognosis  in  view  of  the  fact  that  cancer  may  develop  from  an  ulcer,  the 
course  of  which  has  been  absolutely  latent.) 

The  third  case  is  a  young  student,  twenty-one  years  of  age,  strong  and 
apparently  healthy.  He  has  complained  for  fifteen  months  of  distention 
of  the  abdomen,  with  pressure  and  fullness  there,  capricious  appetite, 
irregular  bowels,  and,  when  these  symptoms  are  present,  of  poor  sleep, 
headaches,  brief  attacks  of  dizziness,  and  conditions  of  anxiety.  He  there- 
fore keeps  a  strict  diet,  refrains  from  all  debauches,  and  tends  to  hypo- 
chondriasis. The  tongue  is  clean,  eructation  and  vomiting  have  never 
been  present,  the  stomach  contents  as  well  as  the  size  of  the  stomach  are 
normal,  and  we  would  be  inclined  to  regard  this  case  as  one  of  nervous 
dyspepsia,  were  it  not  that  the  iodide  of  potassium  and  salol  tests  both 
agree  in  showing  retardation  of  absorption  and  motion.  I  therefore  do 
not  hesitate  in  pronouncing  this  a  case  of  gastric  insufliciency,  and  the 
result  of  the  treatment  adopted  seems  to  justify  the  diagnosis.  For  two 
weeks  he  has  taken  0"03  [gr.  i]  of  extract  of  nux  vomica  three  times  daily, 
and  has  been  faradized  every  other  day.  Since  this  time  the  attacks  have 
not  appeared. 

In  these  three  eases  I  believe  I  have  presented  various  types  of 
dilatation  and  insufficiency  of  the  stomach.  From  this  it  will  be 
seen  how  the  simple  diagnosis  of  "  dilatation  of  the  stomach  "  does 
not  suffice,  and  how  much  treatment  and  prognosis  are  influenced 
by  the  recognition  of  the  underlying  cause. 


CIIAPTEE  YII. 


CANCEE    OF   THE    STOMACH. 


Although  it  may  be  interesting  to  learn  from  the  various  statis- 
tics which  are  published  from  time  to  time  that  between  0-5  and  2-5 
per  cent  of  the  total  mortahtj  is  due  to  cancer  of  the  stomach,  and 
that  35  to  45  per  cent  of  all  cases  of  cancer  involve  the  stomach,  yet 
such  facts  have  only  a  nosological  interest.  Of  far  greater  unpor- 
tance  is  the  question,  At  ivhat  age  do  persons  most  frequently  suc- 
cumb to  gastric  cancer  ?  The  various  statistics,  of  which  Brinton's, 
based  upon  600  cases,  and  Welch's,  upon  2,0Y5  cases,  are  the  most 
important,  agree  tolerably  well  in  proving  that  three  fourths  of  all 
cancers  of  the  stomach  occur  between  the  fortieth  and  the  seven- 
tieth years  of  life.  The  maximum  habihty  is  between  the  fiftieth 
and  the  sixtieth,  but,  according  to  Lebert,  it  lies  between  the  forty- 
first  and  the  end  of  the  sixtieth  year.  It  is  very  rare  before  the 
thirtieth  year  ;  congenitally  it  almost  never  occurs,  and  the  case  re- 
ported by  Wilkinson  *  must  be  regarded  as  a  very  great  rarity. 
According  to  decades,  its  occurrence  is  as  follows  : 


10  to  20. 

20  to  30. 

30  to  40. 

40  to  50. 

50  to  60. 

60  to  ro. 

TO  to  80. 

80  to  90. 

Welch.... 
Brinton  . . 

2 

55 
11 

271 
31 

55 

499 
63 

96 

620 

88 

95 

428 
100 

61 

140 
52 

13 

60 

Lebert  f . . 

3 

1 

*  Quoted  by  W.  Hayle  Walshe.  The  Nature  and  Treatment  of  Cancer.  Lon- 
don, 1846,  p.  146.  [Other  very  early  cases  of  gastric  cancer  may  be  found  in  Welch's 
article  in  Pepper's  System  of  Medicine,  vol.  ii,  p.  534,  1885.  Scheffer,  Jahrblicher 
fiir  Kinderheilkunde,  Bd.  xv.  Bibliographies  may  be  found  in  C.  Stern,  Deutseh. 
med.  Wochenschr.,  1892,  No.  22 ;  and  Duzan,  Du  cancer  chez  les  enfants.  These 
de  Paris,  1875.— Ed. 

f  Lebert  reports  162  cases. 

313 


314  DISEASES   OP  THE  STOMACH. 

Thus  tile  frequency  in  the  four  decades  between  the  thirty -first 
and  the  completed  seventieth  year  is  94*6  per  cent.  Similar  results 
were  obtained  by  Haberhn*,  whose  statistics  are  based  upon  6,863 
men  and  4,559  women  (18Y7-1886) ;  he  found  72  per  cent  for  the 
period  of  the  fortieth  to  the  seventieth  year,  and  90  per  cent  if  the 
seventieth  to  eightieth  years  be  included.  But,  as  already  stated, 
these  figures  are  only  based  upon  the  relative  morbidity  of  the  dif- 
ferent ages  to  the  total  morbidity  from  cancer.  If  the  frequency 
of  the  disease  were  calculated  for  the  total  number  of  people  living 
in  each  decade,  then  the  ratio  would  increase  in  an  ascending  scale, 
and  would  not  show  a  diminution  after  the  sixtieth  year.  This 
opinion,  which  I  had  expressed  some  time  ago,f  has  been  corrobo- 
rated by  Haberlin.  He  estimates  the  yearly  number  of  deaths  from 
gastric  cancer  per  1,000  persons  to  be  O'l,  0*46,  1-35,  2*67,  3*31  for 
each  decade  from  the  fortieth  to  the  eightieth  year.  Thus  the  con- 
ditions are  the  same  as  in  phthisis,  the  relative  frequency  of  which, 
as  estimated  for  the  total  number  of  people  living  at  that  period, 
steadily  increases  with  advancing  age.  The  disease  also  seems  to  be 
distributed  differently  in  different  regions.  Griesinger  never  saw 
any  case  of  it  in  Egypt,  while  Cloquet  and  Autenrieth  found  it 
unusually  common  in  ISTormandy  and  the  Black  Forest  [Baden] 
respectively.  Haberlin  concludes  that  twice  as  many  cases  of  can- 
cer of  the  stomach  occur  in  Switzerland  as  in  Berlin  and  Yienna. 

Sex  appears  to  exert  no  influence  on  the  frequency  of  gastric 
cancer ;  at  all  events.  Fox's  tabulation  of  the  statements  of  seven 
writers  shows  that,  of  1,303  cases,  680  were  males  and  623  females , 
in  other  words,  both  sexes  were  about  equally  affected,  if  we  allow 
for  the  coincidences  which  are  unavoidable  in  such  a  small  series. 
Ledoux-Lebard,:}:  from  a  study  of  the  mortality  statistics  of  Yienna, 
announces  a  mortality  which  is  about  the  same  for  both  sexes  (100 
in  25,000  deaths  in  a  city  of  a  million  inhabitants).  Of  Welch's 
2,214  cases,  1,233  were  men  and  981  women.  "Wilson  Fox  found 
the  proportion  to  be  52  per  cent  in  men  and  48  per  cent  in  women. 


*  Haberlin.     Ueber  Verbreitung  und  Aetiologie  des  Magenkrebses.     Deutsch. 
Archiv  fiir  klin.  Med.,  Bd.  xliv  und  xlv. 

f  Ewald.     First  American  edition  of  this  work,  p.  263. 
X  Ledoux-Lebard.    Arch,  gener.  de  med.,  avril,  1885. 


HEREDITY  OF   CANCER.  315 

Brautigam  found  the  relation  to  be  3 : 2  in  Bavaria,  and  Haberlin  7 :  5 
in  Switzerland. 

It  would  be  very  important  if  we  could  come  to  a  definite  con- 
clusion regarding  the  heredity  of  cancer.  Not  alone  in  tbe  diag- 
nosis of  a  suspicious  case,  but  also  in  tlie  prognosis  as  to  the  prob- 
able duration  of  life  of  the  children  of  cancerous  parents,  an  im- 
portant part  is  played  by  this  question  of  the  heredity  of  cancer,  it 
being  self-evident  that  cancer  of  the  stomach  is  included  in  the 
general  sphere  of  carcinomatous  affections.  All  authors  who  have 
studied  the  origin  of  carcinoma,  even  to  the  most  recent  date  (a 
good  resume  of  this  discussion  will  be  found  in  J.  E.  Alberts's 
book  *),  agree  that  cancer  is  hereditary  in  the  sense  that  the  predis- 
position is  transmitted  from  the  sufferer  to  his  descendants,  and 
this  it  is  which  may  develop  under  certain  conditions.  But  what 
are  these  conditions  which  influence  the  transmission  and  subse- 
quent development  of  the  disease ;  how  often  are  the  subjects 
attacked — in  other  words,  how  frequently  do  the  children  of  carci- 
nomatous parents  acquire  the  disease,  and  what  cause  may  be  discov- 
ered for  this  ?  This  is  really  the  practical  side  of  the  question ;  but, 
strange  to  say,  it  is  scarcely  broached  in  these  works,  while  its  great 
importance  is  manifest,  and  confronts  us  daily.  But  here,  with  the 
exception  of  a  few  statistics,  we  are  almost  exclusively  compelled 
to  use  more  or  less  subjective  (and  hence  unreliable)  opinions,  while 
the  information  obtained  from  the  relatives  of  the  deceased  patients 
is  always  interpreted  very  differently  by  different  physicians,  yet 
nearly  always  in  the  view  of  heredity.  Not  alone  may  cancer  of 
the  stomach  be  directly  transmitted  from  parents  to  children,  but 
more  frequently  the  preceding  generation  has  had  a  different  variety 
of  cancer ;  in  mothers  the  uterus  or  mamma  has  been  especially  fre- 
quently involved. 

The  life-insurance  companies,  which  naturally  are  vitally  inter- 
ested in  this  question  of  the  heredity  of  cancer,  do  not,  as  a  rule, 
reject  a  candidate  on  account  of  the  death  of  one  parent  from  this 
disease ;  yet  it  is  considered  to  increase  the  risk,  and  a  higher  pre- 
mium must  be  paid.     This  is  based  upon  their  practical  experience  : 

*  J.  E.  Alberts.  Das  Carcinom  in  historischer  und  experimcntell-patholo- 
giseher  Beziehung.    Jena,  1887. 


316  DISEASES  OP  THE  STOMACH. 

thus,  for  example,  in  a  period  of  fifty  years,  from  1829  to  IS'TS,  the 
Gotha  Life  Insurance  Company  had  334  deaths  from  cancer ;  of 
these,  31 — i.  e.,  9'3  per  cent — were  hereditary.  Lebert  found  he- 
redity in  7  per  cent  of  his  cases ;  Haberlin  has  analyzed  138  cases, 
and  has  found  positive  evidence  of  gastric  cancer  in  the  parents 
in  8  per  cent,  in  brothers  and  sisters  2*2  per  cent ;  probable  gastric 

•  •  •  •  • 

cancer  m  parents  m  4:"3  per  cent,  uncertam  m  5  per  cent ;  cancer 
in  other  organs,  2'9  per  cent.  In  1T8  cases  of  my  own,  the  his- 
tories of  which  were  taken  as  carefully  as  possible,  heredity  ex- 
isted in  only  6"Y  per  cent.  ISTevertheless,  in  this  and  similar 
statements,  no  attention  is  paid  to  the  fact  that  the  disease  often 
occurs  in  families  in  which  there  is  no  hereditary  predisposition. 
H.  Snow,  physician  to  the  London  Cancer  Hospital,*  has  an- 
swered the  question,  to  the  effect  that  in  1,075  cases  of  carcinoma 
in  different  parts  of  the  body,  16Y — i.  e.,  15*7  per  cent — stated 
that  the  disease  had  already  occurred  in  their  families,  it  being 
understood  that  the  transmission  is  not  always  direct,  but  that 
it  has  affected  more  than  one  member  of  the  family.  On  the 
other  hand,  among  175  patients  who  were  under  treatment  for  non- 
cancerous affections,  46 — i.  e.,  26  per  cent — admitted  that  cancer 
had  occurred  in  their  families  ;  and  in  two  other  series,  of  78  and 
79  cases  respectively,  the  former  being  healthy  individuals,  the  latter 
patients  with  pulmonary  diseases,  the  relative  percentages  were  19'2 
and  11-3.  It  is  manifest  that  statistics  of  this  kind  are  very  uncer- 
tain, since  it  can  not  be  demonstrated  whether  the  patients  in  ques- 
tion have  not  or  would  not  have  fallen  victims  to  the  disease.  The 
statements  of  Eoth  f  are  entirely  different ;  an  analysis  of  the  mor- 
tality records  of  Laenggries  in  Bavaria,  from  1682  to  1885,  shows 
an  inheritance  of  cancer  in  more  than  half  the  cases.  But  here  the 
reliability  of  the  data  may  be  questioned,  and,  moreover,  the  range 
of  observation  is  too  limited. 

[Graf  X  lias  carefully  studied  the  question  of  heredity  in  4,233 
cases  of  cancer  of  all  kinds  which  he  had  collected.     He  found 

*  H.  Snow.    Is  Cancer  Hereditary  ?    British  Medical  Journal,  October  10, 1885. 

t  Roth.    Ueber  Erblichkeit  des  Krebses.    Friedreich's  Blatter,  1889,  pp.  26  to  45. 

X  [Graf.  Ueber  das  Carcinom  mit  besonderer  Beriicksichtigiing  seiner  Aetiologie, 
Hereditat  imd  seines  endemischen  Auftretens.  Archiv  fiir  klin.  Chirurgie,  Bd,  1, 
Heft  i.    Contains  complete  bibliography. — Ed.] 


ETIOLOGY  OF  GASTRIC   CANCER.  317 

that  cancers  were  decidedly  hereditary  in  certain  families,  and  that 
it  occurred  more  frequently  in  some  districts  than  in  others.  The 
latter  was  especially  true  of  cancers  of  the  digestive  tract.  This  was 
especially  noticeable  where  the  population  was  more  exposed  than 
elsewhere  to  irritative  conditions  of  this  tract.  Thus  we  may  ex- 
plain the  frequency  with  which  husband  and  wife  or  members  of 
certain  families  are  attacked,  because  they  are  exposed  to  the  same 
irritant  action  of  certain  strongly  seasoned  or  indigestible  articles 
of  food.] 

Etiology. — In  discussing  this  question  of  the  hereditary  transmis- 
sion of  carcinoma  of  the  stomach,  I  have  already  encroached  upon 
the  question  of  the  individual  causes  of  the  disease.  In  general, 
it  must  be  admitted  that  we  are  just  as  ignorant  of  the  etiology  here 
as  elsewhere.  I  may  enumerate  a  list  of  so-called  etiological  factors, 
because  in  a  number  of  cases  we  have  observed  a  transient  connec- 
tion, and  a  more  or  less  evident  transition,  which  is  called  cause  and 
effect ;  yet  it  is  not  known  why  these  causes  are  in  some  cases  fol- 
lowed by  a  carcinomatous  proliferation,  and  why  in  others  tbere  is 
no  reaction  whatsoever.  Nevertheless,  some  of  the  factors  to  be 
mentioned  presently  occur  so  frequently  that  they  must  exert  some 
influence  on  the  origin  of  carcinomatous  tumors.  A  discussion  of 
this  question  is  in  place  in  a  general  consideration  of  the  nature  of 
carcinoma  ;  this  lies  within  the  province  of  general  pathology,  and 
hence  is  out  of  place  here*. 

I  shall  simply  limit  myself  to  a  brief  resume  of  the  possible 
etiological  factors.  All  of  these  partake  more  or  less  of  the  char- 
acter of  irritants  which  may  be  due  to  the  ingestion  of  acrid  sub- 
stances, or  which  may  result  from  acute  or  chronic  inflammatory 
processes.  Among  these  may  be  included  corrosion  by  nitric  acid 
and  arsenic ;  of  the  former,  Andral  is  said  to  have  reported  an  ex- 
ample, but  the  case  is  not  reported  in  the  reference  which  is  copied 
from  one  book  to  another  ;  the  latter  is  regarded  as  a  causal  factor 
by  Dittrich ;  yet  this  is  at  all  events  doubtful,  since  Walshe  found 
a  large  quantity  of  arsenic  encapsulated  in  the  stomach  of  a  patient 


*  An  elaborate  discussion  may  be  found  in  Hauser,  Das  Cylinderepithelcarci- 
nom  des  Magens,  June,  1890. 


318  DISEASES  OF  THE  STOMACH. 

without  any  furtlier  changes  in  its  tissues.*  Traumatisms  have  been 
repeatedly  cited  as  causes  of  gastric  cancer.  For  example,  Alberts  f 
reports  the  following  case  :  A  man  who  up  to  his  fiftieth  year  had 
always  enjoyed  good  health  stumbled  and  fell  against  the  handle 
of  his  umbrella.  Three  weeks  later  gastric  symptoms  appeared,  and 
after  a  year  the  patient  died  of  carcinoma  ventriculi.  A  moment's 
consideration,  however,  will  show  that  this  and  similar  observations 
can  not  definitely  settle  this  question,  since  they  are  not  absolutely 
conclusive.  Who  can  tell  whether  there  was  not  already  a  latent 
cancer,  and  that  the  traumatism  simply  accelerated  its  growth  ? 

Even  in  olden  times  inflammatory  conditions  of  the  mucous 
membrane  of  the  stomach  were  included  among  the  causes  of  gas- 
tric carcinoma.  Such  views  may  be  found  in  the  writings  of  Boer- 
haave  and  Yan  Swieten,  and  in  the  older  works  they  are  met  with 
more  frequently  in  proportion  as  the  nature  of  the  disease  is  less 
known.  But  not  very  long  ago  Schuchardt,:}:  in  a  monograph  enti- 
tled Contributions  to  the  Origin  of  Carcinoma  from  Chronic  Inflam- 
matory Conditions  of  the  Mucous  Membranes  and  Skin,  claims  that 
a  chronic  or  hyperplastic  condition  precedes  the  formation  of  the 
neoplasm,  and  that,  while  this  condition  does  not  necessarily  cause 
the  latter,  yet  it  favors  it  to  a  high  degree. 

Chronic  gastric  ulcers  may  also  be  classed  among  the  predis- 
posing factors.  Lebert  has  observed  the  direct  transformation  of 
ulcer  into  cancer,  and  Dittrich  the  simultaneous  occurrence  of  both 
conditions.  Brinton  cites  cases  in  which  the  lesion,  macroscopically 
an  ulcer  with  thickened  edges,  was  accompanied  by  unquestion- 
able metastases  in  the  liver  and  lungs ;  and  even  states  that  "  an 
unhealed  ulcer  may  at  times  cause  the  development  of  cancerous 
cachexia."  *  C.  Meyer  ||  describes  a  case  of  simple  ulcer  occurring 
with  carcinoma  of  which  the  cell-nests,  although  only  in  the  imme- 
diate vicinity  of  the  ulcer,  were  visible  as  smooth  nodules  which 


*  Walshe,  loe.  cit.,  p.  167. 
f  Alberts,  loc.  cit.,  p.  195. 

X  Schuchardt.     Beitrage.  etc.     Volkmann's  Sammlung  klin.  Vortrage,  No.  257. 

*  Brinton,  loc.  cit.,  p.  248. 

II  C.  Meyer.     Ein  Pall  von  Ulcus  simplex  in  Verbindung  mit  Carcinora.     Inang. 
Dissertation.     Berlin,  1874. 


ETIOLOGY   OF   GASTRIC   CANCER.  319 

had  developed  from  the  epithelium  of  the  ducts  of  the  glands. 
Heitler  *  reports  three  similar  cases  (without  microscopic  examina- 
tion), and  remarks  that  the  diagnosis  carcinoma  ventriculi  ad  hasim 
ulceris  rotundi  is  not  at  all  rare  in  A^enna.  Hauser  f  has  histo- 
logically demonstrated  the  transition  of  ulceration  into  carcinoma- 
tous proliferation,  and  asserts  that  in  one  of  the  cases  examined  by 
him  he  found  not  only  the  secondary  development  of  carcinoma  in 
a  gastric  ulcer  of  very  long  standing,  but  that  "  occasionally  a  can- 
cer may  develop  from  an  affection  of  the  gastric  glands,  even  in  the 
sense  of  the  theory  proposed  for  carcinoma  by  Thiersch  and  Wal- 
deyer."  Flatow  %  reports  a  similar  case  from  the  Pathological 
Institute  at  Munich.  This  case  is  important  because  the  patient 
was  only  twenty-six  years  old,  and  the  history  of  ulcer  was  beyond 
doubt.  The  cancer  was  near  the  pylorus,  and  in  its  center  was  an 
old  scar  with  a  smooth  base.  As  the  result  of  his  microscopical  ex- 
amination Flatow  says,  "  Evidently  there  was  at  first  a  cicatricial 
mass,  and  this  facihtated  an  atypical  proliferation  of  epithelium." 
Hauser's  work  has  since  been  corroborated  by  a  number  of  writers.* 
The  statistics  of  Haberhn's  cases  show  that  Y  per  cent  of  carcinora- 
ata  occurred  after  ulcers. 

[Kelynack  ||  reports  an  interesting  case  of  ulcer  of  the  stomach 
in  a  man,  27  years  old,  who  had  been  ill  for  four  years  with  symp- 
toms which  were  characteristic  of  ulcer,  until  an  actual  tumor  and 
cachexia  became  noticeable  durins^  two  months  before  his  death. 


*  Heitler.  Entwickelung  von  Krebs  auf  narbigem  Grunde  in  Magen  und  in  der 
Gallenblase.  Wiener  med.  Wochenschr.,  1883,  No.  31.  KoUmar  (Zur  Differential 
diagnose  zwischen  Magengeschwlir  und  Magenkrebs.  Berl.  klin.  Wochenschr., 
1891,  Nos.  5  and  6)  has  collected  only  14  cases  from  the  literature.  This,  however, 
gives  an  erroneous  idea  of  the  frequency  of  this  occurrence,  because  all  the  cases  of 
this  well-known  fact  are  not  published. 

f  Hauser.  Das  chronische  Magengeschwiir  und  dessen  Beziehung  zur  Entwick- 
elung des  Magencarcinoms.     Leipzig,  1883,  S.  70  und  73.     Also  loc.  cit. 

X  H.  Flatow.  Ueber  die  Entwickelung  des  Magenkrebses  aus  Narben  des  run- 
den  Magengeschwiirs.     Inaug.  Dissert.     Mlinchen,  1887. 

*  Stienon.  Contribution  a  I'anatomie  pathologique  de  I'ulcere  de  I'estoinac. 
Bruxelles,  1889. — Kulcke.  Zur  Diagnose  und  Therapie  des  Magencarcinoms. 
Inaug.  Dissert.,  Berlin,  1889. — Rosenheim.     Berl.  klin.  Wochenschr.,  1889,  No.  47. 

II  [Kelynack.  On  the  Occurrence  of  a  Cancerous  Development  in  Simple  Ulcer 
of  the  Stomach.  Brit.  Medical  Journal,  January  18, 1896,  p.  142.  Contains  a  com- 
plete bibliography  and  references  to  all  published  cases. — Ed.j 


320  -  DISEASES  OP  THE  STOMACH. 

At  tlie  autopsy  the  carcinoma  was  found  to  be  limited  to  the  ulcer 
and  its  vicinity.  There  were  no  metastases.  Hydrochloric  acid 
persisted  almost  to  the  end.] 

Concerning  the  other  chronic  irritants  of  the  mucous  membrane 
which  are  supposed  to  favor  the  development  of  cancer,  the  various 
exceptions  are  so  evident  that  a  discussion  on  the  unreliabihty  of 
such  evidence  is  superfluous.  The  same  is  true  of  bacterial  origin 
and  transmission  of  cancer,  as  shown  in  the  experimental  and  bacte- 
riological researches  of  Alberts,  Schill,  Scheurlen,  Adamkiewicz, 
Sanarelli,  and  Barbei.  Hauser  has  presented  strong  arguments 
against  this  doctrine  ;  he  directs  especial  attention  to  the  histological 
differences  in  the  tissue  changes  produced  by  carcinoma  and  by  bac- 
teria, and  also  to  the  primary  difference  in  the  histogenetic  origin 
and  formation  of  metastases  in  each.  Furthermore,  he  has  shown 
that  all  so-called  inoculations  of  cancers  are  nothing  more  than  suc- 
cessful  transplantations  of  living  tissues  which  have  proliferated  at 
the  point  of  inoculation. 

Pathological  Anatomy. — After  a  thorough  investigation,  Wal- 
deyer  was  the  first  to  teach  that  the  disease  is  developed  from  the 
glandular  elements  of  the  mucous  membrane — i.  e.,  from  the  peptic 
glands,  and  especially  from  the  mucous  glands  of  the  pylorus.  The 
process  is  an  atypical  glandular  proliferation  which  bursts  through 
the  muscularis  mucosae,  and  extends  into  the  submucosa.  In  the 
cells  of  these  proliferating  glands,  as  has  been  shown  by  Hauser  and 
Hansemann,*  numerous  karyokinetic  figures  may  be  demonstrated. 
In  the  deeper  layers  of  the  tissues  there  is  formed  a  richly  reticu- 
lated network  with  many  anastomoses,  the  outlying  branches  of 
which,  as  1 1  have  demonstrated  years  ago,  penetrate  deeply  into  the 
apparently  healthy  tissues  in  the  form  of  long  tubules  filled  with  cu- 
boidal  epithelium.  Thus  circumscribed  cancerous  nodules  are 
formed  ;  these  coalesce  later  on,  and  thus  necessitate  the  subsequent 
flattened  growth.  Coincidently  there  is  an  active  growth  of  the 
connective  tissue  which  soon  exceeds  the  proliferation  of  the  gland- 
ular elements,  and  thus  at  first  produces  an  hypertrophy  of  the 


*  Hauser,  loc.  cit. — Hansemann.     Virch.  Arch.,  1890,  Bd.  cxix,  p.  299. 
t  Ewald.     Berl.  klin.  Wochenschr.,  1888,  p.  995. 


PATHOLOGY   OP   GASTRIC   CANCER.  321 

connective  tissue,  while  the  glandular  elements  still  remain  nor- 
mal. Later,  it  extends  along  the  proliferated  glandular  tubules 
and  manifests  itself  as  a  small-celled  infiltration  about  the  cancer 
nodules. 

After  Korcynski  and  Jaworski  *  had  laid  much  stress  upon  the 
relation  between  carcinoma  and  catarrhal  gastritis,  Kosenheim,  Mat- 
thieu,  and  myself  f  have,  a  number  of  years  ago,  carefully  studied 
the  mucous  membrane  which  was  not  involved  by  the  carcinomatous 
process.  Their  statements  have  been  corroborated  and  augmented  by 
Fischl,:}:  who  examined  15  cases,  and  myself,  in  two  cases  in  which  I 
was  able  to  make  sections  from  fresh  tissue  which  was  cut  from  the 
periphery  of  the  cancerous  tumor  at  operations.  According  to  these 
authors,  the  mucosa  is  inflamed  far  beyond  the  seat  of  the  neoplasm, 
being  manifested  by  a  more  or  less  pronounced  interstitial  gastritis 
with  its  characteristic  granular  degeneration  of  the  glandular  cells, 
cystic  enlargement  of  the  tubules,  and  atrophy  of  the  mucosa,  as 
already  described  on  page  200. 

Yarieties. — Any  of  the  various  forms  of  cancer — scMrrus^  en- 
cephaloid,  colloid,  polypoid,  and  telangiectatic — may  occur  in  the 
stomach.  All  authors  state  that  the  first  is  the  most  common.  Ac- 
cording to  Brinton,  it  occurs  in  75  per  cent  of  all  cases,  while  the 
colloid  is  found  only  in  from  2  to  8  per  cent.  If  we  agree  with 
Waldeyer  *  that  the  nature  of  the  disease  consists  in  "  an  atypical 
transformation  of  epithelium,"  then  the  above-mentioned  individual 
varieties  are  one  and  the  same  fundamental  process,  and,  as  actually 
occurs,  often  change  into  one  another. 

ScirrTius,  carcinoma  simplex  or  fibrosum,  with  its  predominant 
development  of  dense  connective-tissue  stroma,  and  with  relatively 
few  cell-nests,  has  a  firm  and  compact  structure.  It  occurs  some- 
times as  large  masses  or  tubercles,  sometimes  as  small  nodules  ;  at 
times  multiple,  but  oftener  as  a  diffuse  infiltration.     It  creaks  when 

*  Korcynski  und  Jaworski.     Deutsch.  med.  Wochenschr.,  1886.  Nos.  47-49. 

t  Ewald.  Klinik,  etc.,  1888.— Rosenheim.  Berl.  klin.  Woch.,  1881,  Nos.  51,  52. 
— Matthieu.     Archiv.  gen.  de  med.,  avril,  1889. 

X  Fischl.  Die  Gastritis  bei  Carcinom  des  Magens.  Prager  Zeitschr.  filr  Heil- 
kunde,  1891,  Heft  3. 

*  Waldeyer.  Die  Entwickelung  der  Carcinome.  Virchow's  Archiv,  Bd.  Iv, 
S.  54. 


322  DISEASES  OF  THE  STOMACH. 

cut,  and  the  section  presents  an  almost  cartilaginous  tissue  of  a 
white,  grayish-yellow,  or  dull  yellow  color,  with  yellow  or  red 
spots  scattered  here  and  there ;  it  may,  however,  have  a  smooth 
and  shining  surface,  almost  like  bacon. 

Where  there  is  a  tendency  to  ulceration  we  find  a  rich  vascular 
network,  and  also  an  extensive  diffuse  redness;  where  ulceration 
has  already  begun,  an  undulating  fissured  surface  is  presented 
by  the  ulcer,  which  is  covered  with  ragged  greenish-yellow  or 
black  detritus.  Of  frequent  occurience  are  fatty  degeneration  and 
atrophy  in  some  parts,  while  in  others  it  continues  to  grow.  Firm 
pressure  will  cause  a  small  amount  of  turbid,  milky  cancer  juice  to 
exude. 

Encephaloid  cancer^  carcinoma  medullar e^  is  soft,  has  very  little 
connective-tissue  stroma,  but  is  very  rich  in  vessels  and  cells ;  the 
growth  is  spongy,  and  cuts  easily ;  the  cut  section  is  whitish-yellow 
in  color,  and  resembles  brain  matter  both  in  color  and  consistency. 
It  undergoes  colloid  degeneration  more  frequently  than  does  the 
scirrhus.  Extravasations  of  blood  are  frequent,  and  are  marked  by 
their  characteristic  discoloration. 

If  the  cells  in  an  otherwise  well-developed  stroma  show  from 
the  beginning  a  tendency  to  undergo  colloid  degeneration,  then  the 
whole  growth  assumes  a  gelatinous  appearance  somewhat  resembling 
glue.  Thus  arises  the  colloid  carcinoma,  carcinoma  alveolare  or 
gelatinosum.  On  cutting  and  scraping,  a  true  cancer  juice  does  not 
exude,  but  instead  gelatinous  fragments. 

Yillous  carcinom,a,  Zottenhrehs,  carcinoma  villosum,  is  produced 
by  villous  or  papillary  outgrowths  in  the  scirrhus  or  medullary 
varieties.  If  the  development  of  blood-vessels  predominates,  the 
growth  is  called  a  telangiectatic  carcinoma  or  fungus  hcBmatodes. 
Finally,  if  there  are  numerous  hsemorrhages  into  the  cancerous  tis- 
sues, any  of  the  varieties  of  the  neoplasm  may  assume  the  char- 
acter of  a  melam,otic  carcinoma!^  As  I  have  already  indicated, 
these  various  forms  may  coexist  in  almost  every  variety.     I  shall 

*  [Such  discolored  cancers  ought  not  to  be  confounded  with  true  melanotic 
tumors.  Welch  could  find  no  record  of  true  primary  melanotic  cancers  of  the 
stomach ;  all  of  those  cases  have  proved  to  be  melanotic  sarcomata.  Welch,  loc. 
cit.,  p.  561,  footnote. — Ed.] 


PATHOLOGY  OF   GASTRIC   CANCER.  323 

merely  add  tliat  several  varieties  of  cancer  may  be  found  in  isolated 
areas  in  tlie  same  stomach.  Thus,  for  example,  we  may  find  a 
medullary  carcinoma  at  the  lower  curvature  and  a  scirrhus  at  the 
pylorus. 

In  all  these  types  the  bundles  of  muscular  fibers  are  more  or  less 
infiltrated,  and  undergo  hypertrophy ;  the  muscularis  becomes  paler, 
less  elastic,  and  fragile ;  at  times,  however,  atrophy  may  result. 
Secondary  inflammatory  processes,  with  thickening  and  adhesions  to 
the  adjacent  organs,  are  observed  in  the  serosa. 

Finally,  it  is  to  be  observed  that  other  neoplasms,  such  as  sarcoma 
and  lymphadenoma,  may  also  occur  in  the  stomach ;  their  clinical 
course  can  not  be  distinguished  from  that  of  carcinoma.  Lymph- 
adenomata  are  exceedingly  rare ;  Pitt  *  has  collected  17  cases, 
which  may  be  divided  into  two  groups,  one  in  which  the  new 
growth  begins  in  the  mucosa  and  submucosa,  and  forms  a  soft  tumor 
which  projects  into  the  cavity  of  the  stomach ;  in  the  other  there 
is  a  diffuse  proliferation  under  the  serosa,  which  only  exceptionally 
extends  into  the  submucosa  and  mucosa. 

Having  thus  briefly  recalled  to  mind  the  chief  characteristics  of 
the  different  varieties,  I  shall  now  speak  more  in  detail  of  the  topo- 
graphical features  or  the  localization  of  cancer  of  the  stomach,  and 
of  the  results  thereof. 

"We  must  first  distinguish  between  tumors  which  grow  espe- 
cially on  the  surface  and  involve  large  areas  of  the  mucous  mem- 
brane, and  those  which  attack  only  a  small  portion.  The  former 
are  by  far  the  less  common,  and  are  usually  of  the  medullary  or 
colloid  variety ;  they  are  characterized  by  a  nodular  or  roughened 
surface  like  a  grater ;  they  are  flattened  rather  than  projecting  high 
above  the  surface  ;  other  peculiarities  are  the  frequency  of  assuming 
the  villous  form,  the  occurrence  of  blood  extravasations  and  ad- 
hesions to  the  adjacent  organs,  especially  to  the  peritonaeum  and 
omentum.  In  such  cases  the  greater  portion  of  the  stomach  from 
the  cardia  to  the  fundus  may  be  converted  into  a  carcinomatous 
mass,  yet   such   an  occurrence  is  a  great  rarity.     Otherwise  the 


*  Newton  Pitt.     Lymphadenoma  of  the  Stomach  and   Intestines.     Transact. 
Pathol.  Soc,  London,  1890,  voL  xi. 


324:  DISEASES  OP  THE  STOMACH. 

greater  curvature  usually  remains  free,  and  tlie  neoplasm  preferably 
extends  on  the  posterior  wall  along  tlie  lesser  curvature.  Generally 
the  organ  is  not  increased  in  size,  but  rather  diminished  to  a  firm, 
sausagelike  tumor.  I  have  preserved  such  a  medullary  cancer  in- 
volving the  entire  organ,  which  I  obtained  at  an  autopsy;  the 
capacity  of  the  viscus  was  scarcely  200  c.  c.  [f  ^  vjss.]  of  water. 
The  scirrhus  variety  involves  the  whole  organ  much  less  frequently, 
I  have  two  specimens  of  this  in  which  the  entire  viscus  is  so  infil- 
trated with  a  dense  scirrhus  that  it  looks  like  a  piece  of  intestines. 
In  passing,  I  will  say  that  in  these  cases  the  stomach  could  not  be 
palpated,  so  that  in  one  of  them  the  diagnosis  of  the  neurasthenia 
was  made  by  another  physician,  since  there  were  no  marked  dys- 
peptic symptoms ;  and  even  up  to  a  short  time  before  his  death  the 
patient  had  to  undergo  the  Weir-Mitchell  treatment.  Such  a 
« case  of  scirrhus  is  pictured  in  Fig.  39,  which  is  taken  from  Cars- 
well's  Atlas.*  Usually  scirrhus  follows  the  second  of  the  above 
courses — i.  e.,  it  remains  in  a  circumscribed  portion  of  the  stomach, 
and  tends  to  grow  in  depth  and  height  as  opposed  to  the  superficial 
extension  of  the  medullary  and  colloid  varieties.  This,  however, 
does  not  exclude  its  multiple  occurrence  in  several  parts  of  the 
mucous  membrane  of  the  organ,  as,  for  example,  at  the  pylorus  and 
the  lesser  curvature  or  the  cul-de-sac. 

Concerning  the  situation  of  the  cancer,  nearly  all  the  statistics 
agree  that  in  about  one  half  of  the  cases  the  pylorus  is  involved : 
according  to  Brinton,  60  per  cent ;  Lebert,  59*6  per  cent ;  Katzenel- 
lenbogen,t  58-3  per  cent ;  Luton,:}:  57  per  cent,  etc.  In  between  10 
and  11  per  cent  (Luton,  T'8  per  cent)  it  is  the  cardia  or  the  lesser 
curvature ;  in  the  remainder  the  lesion  is  scattered  over  the  greater 
and  lesser  curvatures.  Of  195  cases  of  gastric  cancer,  Israel  *  found 
the  pylorus  involved  in  128 ;  the  cardia,  26 ;  the  lesser  curvature, 
23 ;  the  greater  curvature,  11 ;  and  flat   carcinoma  of  the   entire 


*  [Sir  Robert  0.  Carswell.     Pathological  Anatomy.     Illustrations  on  the  Ele- 
mentary Forms  of  Diseases,  1833-'38.— Ed.] 

f  Katzenellenbogen.     Beitrage  zur  Statistik  des  Magencarcinoms.     Inaug.  Dis- 
sert., Jena,  1878. 

X  Luton.     Nouv.  dietionnaire  de  med.     Paris,  1871. 

*  Israel.     Berl.  klin.  Wochenschr.,  1890,  No.  29. 


PATHOLOGY  OP  GASTRIC  CANCER.  325 

stomach,  6.  The  fundus  is  attacked  least  frequently  of  all ;  such 
a  case  with  extension  to  the  spleen  was  described  by  Tiingel.* 
Among  the  1,300  cases  reported  by  Welch,  19  were  situated  in  the 
fundus.  At  all  events,  the  orifices  are  the  favorite  sites — 70  to  75 
per  cent ;  thus  cancer  differs  markedly  from  ulcer  in  this  respect,  as 
the  latter  involves  the  orifices  about  five  times  less  frequently — i.  e., 
16  to  18  per  cent. 

The  situation  and  extent  as  well  as  the  consistency  of  the  neo- 
plasm influence  the  shape  and  position  of  the  stomach  in  the  follow- 
ing ways : 

1.  The  viscus  may  become  smaller  by  a  concentric  contraction, 
as  where  a  firm  tumor  involves  the  stomach  in  toto — i.  e.,  infiltra- 
tion of  the  mucosa  and  muscularis  ;  or,  finally,  even  a  narrowing  of 
the  lumen  by  extension  inward,  as  shown  in  Fig.  39.  It  may  also 
result  from  tight  strictures  situated  at  the  cardia ;  as  a  consequence 
of  this,  the  absence  of  the  normal  pressure  of  the  contents  of  the 
stomach  upon  its  walls  causes  the  organ  to  contract  into  the  smallest 
possible  volume,  since  it  must  yield  to  its  elastic  tissues  ;  its  diame- 
ter may  be  diminished  to  that  of  the  large  intestines,  as  occurred  in 
the  case  which  I  have  already  described  on  page  94  (Fig.  12). 
While  the  patient  was  alive  the  pancreas  and  stomach  could  be 
palpated  through  the  relaxed  abdominal  wall  as  a  hard  nodular 
tumor. 

2.  Dilatation  is  always  the  result  of  a  tumor  obstructing 
the  pylorus.  Here  the  stenosis  may  be  due  to  all  the  various 
causes  which  have  been  fully  described  under  dilatation  of  the 
stomach. 

3.  Changes  in  the  position  of  the  stomach  are  produced  by  the 
weight  of  the  tumor  ;  this  may  be  so  marked  that  either  the  fundus 
or  the  pylorus,  alone  or  both  together,  may  be  dragged  down  deeply 
into  the  pelvis,  and  may  contract  adhesions  with  its  organs,  the 
ovaries,  uterus,  bladder,  etc. 

4.  Distortions,  l)ends,  and  constrictions  of  the  stomach  may  be 
developed  as  a  consequence  of  the  inflammatory  adhesions  with  ad- 


*  TiingeL     Klinische  Mittheilungen  aus  dem  Hamburger  Krankenhause,  1860, 

S.  108. 


326 


DISEASES  OF  THE  STOMACH. 


Fig.  39.— Scirrhus  ventr 


iculitotalis  (reduced  to  one  fifth). 


PATHOLOGY  OP   GASTRIC   CANCER.  327 

jacent  viscera,  or  of  the  extension  of  the  new  growth  in  the  stom- 
ach itself. 

These  different  conditions  show  in  what  varied  ways  the  shape 
and  situation  of  the  stomach  may  be  altered. 

Gastric  cancer  occurs  so  overwhelmingly  frequently  as  a  ])ri- 
mary  growth  that  a  case  like  that  reported  by  Cohnheim,  in  which 
the  primary  tumor  was  situated  in  the  mamma,  must  always  be  con- 
sidered a  great  rarity.  Ely  *  has,  however,  collected  13  cases,  in 
which  the  primary  cancer  was  in  the  cesophagus  in  6  cases,  in  the 
mamma  in  3,  in  the  testicle  in  2,  and  once  each  in  the  leg,  supra- 
renal capsule,  and  colon.  On  the  other  hand,  it  is  not  exactly 
rare  to  find  the  disease  occurring  simultaneously  in  a  remote  organ ; 
as,  for  example,  cancer  of  the  stomach  may  coexist  with  a  similar 
growth  in  the  uterus  or  ovaries,  and  no  evidence  can  be  found  to 
indicate  a  metastasis  from  either  organ.  Dittrich  has  never  seen 
the  simultaneous  occurrence  of  the  disease  in  the  stomach  and 
uterus.  In  38  cases  of  gastric  cancer  Haberlin  found  "  metas- 
tasis of  the  uterus  mentioned  only  once."  Recently  I  performed 
an  autopsy  in  a  case  in  which  there  was  found  an  immense  cysto- 
sarcoma  of  the  uterus,  and  a  carcinomatous  infiltration  of  the  py- 
lorus. Secondary  cancerous  metastases  are,  as  is  well  known,  by  no 
means  rare  ;  they  may  affect  any  part  of  the  organism  in  about  three 
out  of  four  cases.  The  liver  is  involved  in  25-6  to  30  per  cent ;  the 
peritonaeum  in  13-T  to  22*7  per  cent ;  the  lungs  and  pleurae  in  0-6 
to  6-2  per  cent ;  while  in  160  cases  collected  by  Dittrich  the  rectum 
was  involved  only  twice,  and  the  ovaries  once.  However  arbitrary 
such  figures  may  be,  according  to  the  cases  at  the  disposal  of  indi- 
vidual writers,  the  evidence  as  to  relative  frequency  of  these  metas- 
tases, as  given  by  Lebert,  is  as  follows  :  In  the  liver,  40-9  per  cent ; 
peritonaeum,  37*5  per  cent ;  lungs,  8*3  per  cent ;  ovaries,  4-5  per 
cent.  Lange's  f  analysis  of  210  cases  at  the  Berlin  Pathological  In- 
stitute gives  different  percentages  :  30-9,  17"6,  0*71,  and  0-14,  re- 
spectively.    Of  greater  practical  interest  is  the  simultaneous  occur- 


*  [J.  S.  Ely.     A  Study  of  Metastatic  Carcinoma  of  the  Stomach.     American 
Journal  of  the  Medical  Sciences,  June,  1890,  p.  584. — Ed.] 

f  Lange.    Der  Magenkrebs  und  seine  Metastasen.    Inaug.  Dissert.    Berlin,  1877. 
22 


328  DISEASES  OF  THE  STOMACH. 

rence  of  metastases  in  important  organs ;  as.,  for  example,  in  the 
liver  and  Imigs,  wliicli  Lange  found  ten  times — ^i.  e.,  4-7  per  cent. 
AlthoTigli  Brinton  asserts  that  the  occurrence  of  metastases  in  the 
liver  naturally  lessens  the  danger  of  involvement  of  the  lungs,  yet 
it  would  seem  more  probable  that,  with  the  establishment  of  two 
cancerous  depots,  the  chances  of  infection  by  transportation  through 
the  vascular  system  would  be  increased.  I  must  confess,  however, 
that  my  own  experience  corroborates  Brinton's  statement. 

That  cancer  and  tuberculosis  do  not  exclude  each  other,  or  that 
both  may  perhaps  be  attributed  to  a  scrofulous  diathesis,  as  was 
formerly  supposed,  needs  no  further  discussion  at  present.  Dis- 
regarding statistical  data — as,  for  example,  Lange,  who  found  them 
together  in  8'1  per  cent  of  his  cases — all  doubt  on  the  subject  has 
been  removed  by  the  direct  observation  of  tubercle  bacilli  in  the 
pulmonary  deposits  in  lungs  which  are  also  cancerous.  It  must  be 
confessed,  however,  that  it  is  at  times  very  difficult  to  decide 
whether  small  cavities  are  due  to  softening  of  tubercular  or  metas- 
tatic carcinomatous  nodules. 

In  many  cases  we  can  explain  the  path  of  the  metastatic  infec- 
tion by  way  of  the  blood  or  lymph  vessels ;  in  others  we  must 
think  of  direct  extension  in  the  continuity  or  along  extra-vascular 
channels  ;  as,  for  example,  the  extension  of  a  pyloric  cancer  to  the 
edge  of  the  liver  or  the  gall  bladder  ;  the  involvement  of  the  colon 
from  a  tumor  on  the  greater  curvature,  or  of  the  diaphragm  and 
lungs  from  one  situated  at  the  cardia  (Carswell  and  Yirchow  *). 

The  formation  of  thrombi  in  various  places  remote  from  the 
stomach  is  also  to  be  explained  by  vascular  transportation  in  so  far 
as  they  are  not  due  to  the  cachexia,  the  altered  condition  of  the 
blood,  and  the  slowing  of  the  circulation,  just  as  is  seen  in  the  veins 
of  the  lower  extremities.  It  has  been  repeatedly  asserted  that  the 
composition  of  the  blood  is  altered,  especially  a  lessening  of  the 
number  of  the  red  blood-cells,  and  of  the  solid  constituents  of  the 
plasma.  I  shall  consider  this  topic  further  when  discussing  the 
symptomatology.  Andral  and  Gavarett  f  state  that  the  percentage 
of  fibrin   is   variable.     There   is   nothing    characteristic   in   these 

*  Virchow.     Die  krankhafte  Geschwulste,  Bd.  i,  S.  54. 

f  Andral  et  Gavarett.     Rech.  sur  la  composit.  du  sang,  p.  238. 


PATHOLOGY  OP  GASTRIC  CANCER.  329 

clianges,  but  they  are  more  or  less  peculiar  to  all  cachectic  con- 
ditions. 

The  swelling  of  the  lymphatic  glands  occurs  less  frequently  in 
this  disease  than  in  neoplasms  elsewhere  which  are  in  close  connec- 
tion with  the  lymphatic  system — for  example,  the  mammary  gland. 
Brinton  has  observed  it  in  only  23*5  per  cent  of  his  cases,  although 
Welch  gives  a  higher  figure,  35  per  cent.  In  this  connection  I 
would  refer  to  the  statements  I  have  already  made  on  page  123. 
We  must,  however,  distinguish  between  a  simple  swelling  and  can- 
cerous degeneration  of  the  glands.  The  latter  would  be  observed 
much  more  frequently  if  attention  were  not  alone  paid  to  the  glands 
which  are  visible  and  palpable,  but  also  to  the  entire  lymphatic  sys- 
tem. Lebert  gives  the  high  percentage  of  54*5,  though  Katzenel- 
lenbogen  places  it  lower,  40  per  cent.  The  swelling  of  the  supra- 
clavicular glands,  which  was  first  claimed  by  Henoch  and  Yirchow, 
and  later  by  many  others,*  to  be  a  pathognomonic  symptom,  is,  in 
my  experience,  a  rare  and  by  no  means  constant  occurrence.  [Le- 
pine  f  observed  it  in  only  three  out  of  40  cases  of  gastric  cancer  on 
which  autopsies  had  been  performed.  He  reports  one  case  in  which 
the  left  supraclavicular  gland  was  larger  than  a  hen's  egg,  although 
the  gastric  tumor  could  only  be  palpated  with  great  difficulty.] 

Ulceration  occurs  to  a  very  variable  extent  in  gastric  cancer, 
sometimes  as  simple  superficial  erosions,  sometimes  as  a  single  round 
or  oval  ulcer,  not  infrequently  having  an  orifice  like  a  crater  with 
a  thick,  wall-like  edge.  Ulceration  occurs  most  frequently  in  the 
medullary  variety,  less  often  in  the  scirrhous,  and  least  of  all  in  the 
colloid.  Although  the  process  usually  has  a  progressive  tendency, 
yet  sometimes  carcinomatous  ulcers  may  be  found  with  the  central 
portion  cicatrized  (whence  the  saying  that  cancer  is  curable),  but  in 
the  edges  of  which  new  foci  continue  to  be  formed.  Erosion  of 
the  blood-vessels  may  lead  to  small  or  large  haemorrhages  with  their 
subsequent  tissue  changes.  If  the  mucous  membrane  is  totally  de- 
stroyed, we  then  find  the  submucous  connective  tissue  covered  with 
florid,  blackish  fragments  of  the  destroyed  membrane,  or  its  surface 

*  Troisier.    Les  gangliones  sus-clavieulaires  dans  le  cancer  de  I'estomac.     Gaz. 
hebdom.,  1886,  No.  42. 

f  [Lepine.    Deutsch.  med.  Wochenschr.,  1894,  p.  298.— Ed.] 


330  DISEASES  OF  THE  STOMACH. 

may  be  entirely  bare,  excepting  bere  and  tbere  a  few  vascular  loops. 
In  a  similar  way  arise  the  villous  fungosities  on  tbe  surface  of  an 
ulcerated  carcinoma  ;  yet  these  must  be  carefully  distinguished  from 
the  benign  true  polypi  of  the  mucous  membrane. 

Ulceration  may  lead  to  perforation ;  this  is  comparatively  infre- 
quent. Brinton  estimates  its  occurrence  at  about  4  per  cent.  The 
intestines  and  peritongeum  are  most  frequently  involved,  especially 
the  transverse  colon ;  these  communications  being  sometimes  of  a 
fairly  large  size.  If  an  adhesive  peritonitis  has  preceded,  the  per- 
foration may  at  times  lead  to  the  formation  of  an  encapsulated  sac, 
which  in  rare  cases  may  perforate  the  abdominal  wall  in  the  form 
of  an  abscess.  Altogether  sixteen  such  cases  have  been  reported, 
according  to  a  compilation  by  Mislowitzer ;  *  to  these  must  be  added 
another  case,  which  occurred  in  Gerhardt's  clinic.  Dittrich  has 
seen  a  case  in  which  the  perforation  was  into  the  ileum  after  com- 
plete closure  of  the  pylorus  had  taken  place ;  and  thus  by  natural 
means  a  collateral  communication  between  the  stomach  and  intes- 
tines was  established,  such  as  we  endeavor  to  obtain  by  operation  in 
similar  cases. 

General  Clinical  History. — Cancer  of  the  stomach  is  an  exceed- 
ingly insidious  disease,  and  at  the  outset  is  not  to  be  distinguished 
from  other  affections  of  the  organ  which  lead  to  dyspepsia.  Brin- 
ton's  epigrammatic  description,  "  Obscure  in  its  symptoms,  frequent 
in  its  recurrence,  fatal  in  its  event,"  is  true  even  to-day  in  spite  of 
the  great  improvement  in  our  diagnostic  and  therapeutic  resources. 
Irregularity  and  impairment  of  the  appetite,  slowing  and  disturb- 
ance of  digestion,  a  feeling  of  pressure,  fullness,  and  tension  in  the 
epigastrium,  also  regurgitation  of  food  and  a  tendency  to  nausea, 
together  with  more  or  less  obstinate  constipation,  open  the  scene. 

In  Beau's  statement  that  gastric  cancer  is  often  preceded  by  a 
period  of  "  idiopathic  dyspepsia,"  f  the  word  often  ought  to  be 
changed  to  seldom  :  for,  on  the  contrary,  it  is  surprising  how  fre- 
quently patients  assert  that  they  have  always  had  good  stomachs, 
and  that  they  have  always  been  moderate  in  eating  and  drinking. 

*  E.  Mislowitzer.     Ueber  die  Perforationen  des  Magenearcinoms  nach  aussen. 
Inaug.  Dissert.,  Berlin.  1889. 

f  Beau.     Gazette  d.  hopit,  1859,  p.  390. 


SYMPTOxMS  OP  GASTRIC  CANCER.  33I 

While  the  gluttons  have  themselves  to  blame  to  some  extent  for 
their  dilated  stomachs,  the  unfortunate  victims  of  gastric  cancer 
have  not  even  the  melancholy  satisfaction  that  in  the  days  of  health 
their  stomachs  had  afforded  especial  joy  and  pleasure. 

It  is  only  gradually  that  pain  in  the  stomach,  local  or  diffused  or 
cardialgic  in  character,  is  added;  then  vomiting  occurs,  usually 
without  any  great  exertion  and  without  marked  nausea.  The  tongue 
becomes  thickly  coated,  and  especially  in  the  morning  has  a  tena- 
cious white  fur,  which  is  scraped  off  with  difficulty  and  is  soon  re- 
newed. Lebert  seldom  found  the  tongue  coated,  and  considered 
this  cleanness  of  the  tongue  one  of  the  most  important  paradoxical 
manifestations  of  the  disease.  My  experience  is,  however,  different ; 
I  have,  indeed,  seen  patients  whose  tongues  remained  relatively 
clean,  yet  such  cases  are  exceptions.  The  coated  condition  of  the 
tongue,  either  in  toto  or  with  the  exception  of  the  edges  and  isolated 
papillae  which  project  like  berries,  is,  quite  on  the  contrary,  to  be 
regarded  as  an  important  point  in  the  differential  diagnosis  from 
gastric  ulcer.  A  striking  repugnance  toward  meat,  and  other  anoma- 
lies of  taste  and  appetite,  precede  complete  anorexia.  A  patient 
of  mine  stated  that  claret  suddenly  tasted  like  ink.  One  of  Brin- 
ton's  patients  abruptly  lost  all  desire  for  smoking,  although  strongly 
addicted  to  the  habit.  This,  combined  with  a  cachectic  appearance, 
led  the  physician  to  diagnose  a  cancer  which  was  subsequently  dem- 
onstrated, although  the  other  symptoms  did  not  indicate  it.  The 
taste  becomes  flat  and  ''  pasty,"  bitter  or  sour,  or  the  mouth  may 
become  foul  in  spite  of  all  attempts  at  rinsing  and  cleansing.  The 
pain  becomes  more  intense  and  at  times  paroxysmal,  and  occurs  not 
only  after  the  scanty  meals  but  also  between  them  and  at  night. 
Vomiting  is  more  frequent ;  while  at  first  the  vomit  consists  chiefly 
of  mucus,  remnants  of  food,  and  watery  fluid  mixed  with  bile,  in 
time  the  food  is  vomited  in  a  more  and  more  undigested  condition. 

The  vo7mt  is  sometimes  tasteless,  sometimes  sour,  has  a  pene- 
trating or  offensive  odor,  and  where  perforation  has  occurred  into 
the  intestines  it  may  even  have  a  fecal  odor.  Various  kinds  of 
epithelium  and  micro-organisms  (Fig.  40)  are  usually  present  (see 
page  304).  The  vomited  matter  may  often  contain  blood,  either  in 
small  amounts  as  bright-red  streaks  in  the  mucus,  or  in  large  quan- 


333 


DISEASES  OP  THE  STOMACH. 


titles  as  bright-red  or  brownisli-red  clots  or  brown,  chocolate-colored 
to  black  coagula  and  masses — the  well-known  cofEee-ground  vomit ; 
these  differences  are  due  to  the  length  of  time  the  blood  has  re- 
mained in  the  stomach,  and  to  the  extent  of  the  decomposition 
caused  by  its  contents.  Although  hsematemesis  when  it  does  occur 
in  cancer  of  the  stomach  is  usually  a  late  symptom,  yet  in  rare 
cases  it  may  take  place  at  the  beginning  of  the  disease.  Thus,  Mey  * 
reports  three  cases  in  which  profuse  haemorrhage  from  the  stomach 
was  the  first  symptom  given  by  the  patients.  The  autopsy  in  each 
case  revealed  scirrhous  cancer  of  the  stomach,  the  consistency  and 
character  of  which  eliminated  the  possibility  of  having  arisen  from 
an  ulcer. 


Fig.  40. 


The  vomit  from  which  this  drawing  was  made  consisted  of  a  clear, 
reddish  fluid,  with  a  light,  flocculent  deposit,  in  which  dark-brown  par- 
ticles resembling  snufp  were  suspended.  The  filtrate  contained  no  free 
acid,  but  small  amounts  of  lactic  acid  were  present;  has  no  digestive 
action  unless  hydrochloric  acid  is  added.  Under  the  microscope  may  be 
seen  the  outlines  of  red  blood-cells,  granular  masses  stained  with  blood 
pigment,  epithelium  of  the  oesophagus  and  stomach,  some  of  which  look 
like  peptic  cells ;  others  are  distinctly  cylindrical.     There  are  also  yeast- 


*  Edg.  Mey.     Ueber  profuse  Magenblutungen  und  Hydrops  Anasarca  als  initiale 
Symptotae  des  Magenearcinoras.     Dissert.,  Dorpat,  1891. 


SYMPTOMS  OF  GASTRIC   CxVNCER. 


333 


cells,  aud  also  cells  of  another  variety  of  fungi,  probably  an  aspergillus. 
A  dense  network  of  delicate  and  coarse  fungous  filaments  (which  is  mei*ely 
indicated  in  the  figure)  incloses  the  above-mentioned  brownish  detritus 
which  is  visible  to  the  naked  eye.  There  are  also  many  cocci  and  drops 
of  fat.  The  peculiar  fibers  to  the  left  of  the  figure,  resembling  elastic 
fibers  of  the  lungs,  are  from  the  connective  tissue  of  the  ingested  meat.  I 
have  repeatedly  observed  these  fibres,  even  in  the  artificial  digestion  of 
meat.  The  patient  asserted  that  he  had  taken  only  milk  for  three  weeks. 
There  is  no  reason  to  doubt  the  truth  of  this  assertion  ;  what  we  find  sim- 
ply proves  how  long  such  I'emnants  may  remain  in  the  folds  of  the  mu- 
cous membrane. 

[Boas  *  and  Oppler  f  have  described  certain  long  bacilli  (Fig. 
41)  whicli  they  found  in  large  number  in  the  stomach  contents  in 
cases  of  gastric  cancer ;  they  are  very  long,  threadhke  bacilli, 
which  have  sharp  bends,  and 
usually  lie  at  an  angle  to  one 
another  and  are  immobile. 
They  believe  that  their  pres- 
ence is  diagnostic  of  cancer 
of  the  stomach.  Kaufmann 
and  Schlesinger, :}:  Kiegel,  * 
Strauss,  |  Manges,  ^  Rosen- 
heim, and  Richter  ()  have  also 
found  them  in  most  cases  of 
cancer.  They  produce  lactic 
acid,  and  Kaufmann  and 
Schlesinger  are  inclined  to 
believe  that  they  are  the  spe- 
cific cause  of  the  formation 
of  lactic  acid  which  is  so  frequently  found  in  this  disease.  This  is 
denied  by  Rosenheim  and  Richter,  who  found  there  bacilli  in  the 
stomach  contents  of  a  case  of  benign  pyloric  stenosis  in  which  HCl 
was  absent,  and  also  assert  that  they  may  occasionally  occur  in  stom- 
ach contents  with  free  HCl. 


[Fig.  41. — Boas  and  Oppler's  long  bacilli ;  from 
the  contents  of  a  cancerous  stomach.  Mag- 
nification, Leitz  I,  7.    From  Eiegel.] 


*  [Boas,  oj).  cit,  Bd.  ii,  p.  182.— Ed.] 

f  [Oppler.     Deutpch.  med.  Wocheiipchr.,  1895,  No.  5. — Ed.] 

X  [Kaufmann  und  Schlesinger.     Wiener  klin.  Rundschau.  1895,  No.  15. — Ed.] 

*  [Riegel.     Krankheiten  des  Magens,  1896,  p.  173.— Ed.] 
II  [Strauss.    Zeitschr.  fur  klin.  Med.,  Bd.  xxviii. — Ed.] 

^  [Manges.    New  York  Med.  Record,  April  27,  1895.— Ed.] 

()  [Rosenheim  und  Richter.    Zeitschr.  fur  klin.  Med.,  Bd.  xxviii. — Ed.] 


334  DISEASES   OF   THE   STOMACH. 

Sarcinse  are  usually  absent  in  gastric  cancer,  for  they  require 
HCl  for  their  growth.  After  a  careful  study  Oppler  *  asserts  that 
sarcinse  occur  only  in  large  numbers  when  the  stagnation  of  the 
chyme  is  due  to  benign  pyloric  stenoses,  severe  gastric  atonies, 
and  occasionally  in  other  noncancerous  diseases  of  the  stomach.  He 
found  that  pure  cultures  of  sarcinse  when  added  to  cancerous  stom- 
ach contents  disappeared  in  a  short  time.] 

The  coffee-ground  vomit  is  not,  as  was  formerly  supposed,  pa- 
thognomonic of  cancer  of  the  stomach ;  yet  it  must  be  admitted 
that  in  this  disease  the  blood  remains  in  the  stomach  for  a  longer 
period  than  in  the  other  diseases  of  this  organ  which  lead  to  hsem- 
orrhages  and  these  subsequent  changes. 

In  most  cases  there  now  appears  a  palpable  (or  also  visible) 
tumor,  which  is  most  frequently  situated  in  the  triangle  formed  by 
the  free  lower  border  of  the  ribs  and  the  linea  umbilicalis  [a  hori- 
zontal line  passing  through  the  umbilicus]  ;  it  is  somewhat  higher  in 
men  than  in  women,  in  whom  the  lower  situation  is  due  to  the 
downward  displacement  of  the  liver. 

Eather  early,  and  not  at  all  proportional  to  the  subjective  feel- 
ings of  the  patient,  occur  marked  loss  of  strength  and  progressive 
emaciation ;  the  superficial  fat  and  the  muscles  rapidly  waste  away, 
till  the  sufferer  soon  drifts  into  a  state  of  extreme  marasmus  and 
exhaustion.  One  of  my  patients,  with  a  distinct  tumor  but  with  a 
surprisingly  good  subjective  condition,  complained  only  at  first  that 
his  limbs  were  becoming  weak  in  climbing  stairs.  Soon  the  charac- 
teristic pale-yellow  color  of  the  cancerous  cachexia  makes  its  ap- 
pearance. After  severe  hsemorrhages  the  countenance  acquires  an 
angemic  or  at  times  a  dropsical  puffiness,  especially  under  the  eye- 
hds.  The  eyes  sink  in,  the  cheeks  become  very  prominent,  the 
features  pointed,  and  the  patients  look  much  older  than  they  are. 
Profound  depression  of  a  melancholy  nature  may  alternate  with 
restlessness  and  excitement.  The  picture  may  be  complicated  by 
neuralgias,  headaches,  dizziness,  and  tinnitus  aurium. 

In  very  rare  cases  neither  anorexia  nor  emaciation  may  occur.  On 
April  8,  1891,  I  performed  an  autopsy  on  a  patient  who  was  brought  into 
the  hospital  on  April  4th,   unconscious  and  hemiplegic.     According  to 

*  [Oppler.     Munchener  med.  Wochenschr.,  1894,  No.  29.— Ed.] 


SYMPTOMS  OF  GASTRIC   CANCER.  335 

the  statement  of  his  friends  he  had  never  suffered  from  any  gastric  symp- 
toms ;  his  general  bodily  condition  was  excellent,  as  was  shown  by  a 
heavy  panniculus  adiposus.  A  tumor  was  found  in  the  right  anterior  cen- 
tral convolution,  and  a  large,  broken-down  cancer  of  the  greater  curva- 
ture of  the  stomach,  with  metastases  in  the  liver. 

For  almost  four  months  I  had  in  my  service  at  the  hospital  a  sixty- 
two-year-old  man  who  suffered  from  chronic  bronchitis,  chronic  pleurisy, 
and  pericarditis,  with  slight  symptoms  of  congestion  and  moderate  gastric 
complaints.  During  all  that  time  I  watched  him  until  he  died  of  pro- 
gressive inanition,  after  having  become  slightly  delirious.  At  the  autopsy, 
in  addition  to  what  was  expected,  a  cancer  of  the  pylorus  with  slight  dila- 
tation of  the  stomach  was  found. 

Similar  cases  of  pyloric  cancers  without  anorexia  and  emaciation 
have  been  reported  by  Siredey,  and  also  by  Muselier.*  Muselier's  patient 
was  a  man,  fifty-eight  years  old,  who,  at  all  events,  had  oedema,  anaemia, 
and  cachexia,  with,  however,  only  slight  dyspepsia  and  a  good  appetite. 
Severe  gastric  symptoms  did  not  appear  until  seventeen  days  before  his 
death. 

The  metastases  in  other  organs — the  liver,  intestines,  Inngs,  etc. — 
the  insidious  or  the  acute  perforations,  may  produce  a  variety  of 
complications  which  in  individual  cases  are  manifested  by  charac- 
teristic symptoms.  Certain  occurrences  are  especially  significant  of 
a  fatal  termination.  Among  these  is  fever,  which  is  neither  a 
marked  nor  a  constant  symptom,  yet  by  no  means  as  rare  as  is 
commonly  supposed.  Its  course  is  irregular,  ranging  usually  be- 
tween 38°  and  39°  C.  [1004°  and  102-2°  Fahr.),  rarely  reaching  40° 
[101°  Fahr.],  and  may,  as  I  saw  in  one  case,  assume  a  purely  hectic 
character.  At  times  absolutely  or  almost  afebrile  periods  may  alter- 
nate with  such  high  febrile  movements  as  can  only  arise  from  sec- 
ondary inflammations.  Hampeln,f  in  a  very  interesting  paper  on 
the  symptoms  of  obscure  visceral  carcinomata,  has  very  accurately 
described  two  cases  of  gastric  cancer  with  an  intermitting  fever, 
which  was  so  marked  that  chills  followed  by  fever  and  sweating 
were  present,  and  the  possibility  of  the  existence  of  malaria  had  to 
be  carefully  considered.  An  interesting  case  of  the  latter  variety 
came  under  my  observation  at  the  Augusta  Hospital. 

A  man,  forty -seven  years  old,  was  admitted  December  6, 1888.  Present 
illness  began  about  two  years  ago  with  symptoms  of  dyspepsia.     In  Sep- 

*  Muselier,     Gaz.  med.  de  Paris,  1891,  No.  1. 

f  P.  Hampeln.  Zur  Symptoraatologie  oceulter  visceraler  Carcinome.  Zeitschr. 
fiir  klin.  Medicin,  Bd.  vlii,  S.  233. 


336  DISEASES  OF  THE  STOMACH. 

tember,  1888,  had  hsematemesis  and  also  passed  blood  per  anum.  He  was 
treated  in  the  hospital  during  October  for  "  ulcer  of  the  stomach,"  and 
was  discharged  improved.  On  December  3d,  violent  vomiting,  but  no 
hsematemesis. 

On  admission  he  was  placed  on  a  milk  diet,  it  being  supposed  that  a 
gastric  ulcer  was  present.  An  irregular  fever  with  evening  exacerbations 
to  39'6°  C.  [103'3°  Fahr.]  soon  manifested  itself.  The  pains  in  the  epigas- 
trium continued,  and  became  variable  in  their  situation,  being  sometimes 
more  marked  to  the  left,  sometimes  to  the  right.  The  stomach  contents 
contained  no  free  hydrochloric  acid.  The  patient  became  more  and  more 
emaciated,  so  that  finally  a  small  tumor  could  be  palpated  in  the  right 
hypochrondrium  near  the  border  of  the  liver.  Icterus  was  not  present. 
A  diagnosis  of  cancer  of  the  stomach  and  liver  was  made.  On  January 
5,  1889,  he  had  a  marked  chill,  which  recurred  several  times ;  the  pains 
in  the  epigastrium  increased,  and  from  now  on  to  the  patient's  death  on 
February  20,  1889,  the  fever  remained  continuous,  and  a  delicate  friction 
sound  could  be  heard  near  the  edge  of  the  liver.  A  diagnosis  was  made 
of  perforation  of  an  ulcerated  cancer  following  an  adhesive  inflammation 
and  agglutination  of  the  adjacent  tissues,  and  also  a  localized  peritonitis. 
The  autopsy  revealed  the  presence  of  an  ulcerated  carcinoma  about  the 
size  of  an  apple,  which  was  situated  on  the  lesser  curvature,  and  which 
reached  to  and  was  adherent  to  the  diaphragm.  The  surface  of  the  liver 
was  studded  with  numerous  slightly  elevated  white  nodules,  all  of  which 
showed  recent  adhesions  to  the  parietal  peritongeum. 

Among  the  terminal  symptoms  are  dropsical  swellings  and  effu- 
sions into  the  serous  cavities ;  in  very  rare  cases  these  may  even 
occur  as  initial  symptoms  ;  *  inflammatory  processes  may  also  occur 
in  the  lungs,  pleurae,  and  kidneys.  As  death  approaches,  delirium 
may  occasionally  be  present ;  this  is  to  be  regarded  as  a  delirium 
due  to  inanition.  Death  is  due  to  marasmus ;  the  agony  is  brief. 
Consciousness  remains  clear  for  a  long  time,  yet  disappears  as 
death  approaches,  so  that  a  conscious  death  struggle  does  not 
occur,  f 

The  condition  of  the  Hood  deserves  especial  notice.  Laache:}: 
was  the  first  to  describe  a  lessening  of  the  number  of  the  red  blood- 
cells  in  this  disease  ;  Lepine  *  called  attention  to  the  temporary  oc- 


*  Mey,  loc.  cit.,  describes  two  cases  in  which  no  other  cause  could  be  found  for 
the  oedema  and  antemia  which  occurred  even  at  the  beginning  of  the  disease. 

f  [Dyspnoeic  coma,  as  in  diabetes,  may  also  occur  in  the  later  stages  of  gastric 
cancer.  Gerhardt's  reaction  may  or  may  not  be  present  in  the  urine.  See  Welch, 
loc.  cit.,  pp.  534  et  seq. — Ed.] 

X  S.  Laache.    Die  Anaemic.     Christiania,  1883. 

*  Lepine  et  Germont.    Note,  etc.     Gazette  med.  de  Paris,  1877,  No.  14. 


SYMPTOMS  OF  GASTRIC   CANCER.  337 

currence  of  numerous  microcytes.  Eisenlolir,*  Schneider, f  and 
Oppenheinier,:]:  besides  the  above  changes,  observed  a  relative  and 
even  an  absolute  increase  in  the  number  of  white  blood-cells,  so 
that  the  condition  of  the  blood  may  resemble  that  of  pernicious 
anaemia,  or  even  of  leucocythsemia ;  Schneider  also  says  that  "  these 
so  easily  recognized  changes  in  the  blood  may  become  a  not  unim- 
portant item  in  the  differential  diagnosis."  Leichtenstern  *  and 
Haberlin  ||  believed  that  the  diminution  in  the  amount  of  haemo- 
globin was  a  characteristic  symptom,  so  that  the  latter  would  ex- 
clude the  possibility  of  gastric  cancer  if  the  haemoglobin  was  about 
60  per  cent.  Laker  ^  urged  that  surgical  interference  ought  to  de- 
pend upon  the  percentage  of  haemoglobin,  Daland  and  Sadler, 
Mouisset,^  and  others,  have  corroborated  the  diminution  in  the  per- 
centage of  haemoglobin.  At  my  request  Ostersprey  ^  studied  this 
subject  in  reference  to  differential  diagnosis  ;  in  12  cases  he  found 
the  number  of  red  cells  lessened  in  7,  an  increase  in  the  white 
cells  in  5,  a  lessening  in  the  amount  of  haemoglobin  in  11.  In 
2  cases,  however,  the  red  cells  were  increased  in  number  with  the 
formation  of  microcytes.  These  changes,  although  pathological, 
have  unfortunately  no  diagnostic  value,  since  similar  changes,  as 
shown  by  Ostersprey,  occur  in  ulcer  of  the  stomach,  and,  as 
shown  by  other  writers,  are  found  in  other  wasting  diseases 
like  tuberculosis,  anaemia,  cirrhosis  of  the  liver,  chronic  perito- 
nitis, etc. 

[It  is  claimed  by  some  ^  that  there  is  no  digestive  leucocytosis  in 
gastric  cancer,  and  attempts  have  even  been  made  to  use  this  as  a 

*  Eisenlohr.  Blut  und  Knochenmark.  Deutehes  Archiv  fiir  klin.  Med.,  Bd. 
XXX,  S.  495. 

f  G.  Schneider.  Ueber  die  morphologischen  Verhaltnisse  des  Blutes  bei  Herz- 
krankheiten  und  bei  Carcinom.     Inaug.  Diss.     Berlin.  1888, 

t  Oppenheimer.     Deutsch.  med.  Wochenschr.,  1889,  No.  42  ef  seq. 

#  Leichtenstern.  Untersuehungen  liber  den  Hamoglobingehalt  des  Blutes  im 
gesunden  und  kranken  Zustand.     Leipzig,  1888. 

II  Haberlin.     Miinchener  med.  Wochenschr.,  1888.  No.  22. 

^  Laker.     Wiener  med.  Wochenschr.,  1886,  No.  18  et  seq. 

0  Daland  und  Sadler.  Fortschritte  der  Med.,  1891,  No.  20.— Mouisset.  Carci- 
nome  de  I'estomac.     Rev.  de  med.,  1891,  No.  10. 

Z  Ostersprey.     Berl.  klin.  Wochenschr.,  1892.  Nos.  12.  13. 

$  [Hartung.  Wiener  med.  Wochenschr.,  October  3,  1835.— Schneyer.  Internet, 
klin.  Rundschau,  1894,  No.  39.— Ed.] 


338  DISEASES  OF  THE  STOMACH. 

means  of  differential  diagnosis.      At  present  no  reliance  can  be 
placed  upon  such  vague  signs.]  * 

The  Changes  in  the  Metaholism. — That  patients  with  cancer  ex- 
crete very  little  urea  in  spite  of  the  ingestion  of  relatively  larger 
amounts  of  food,  and  that  there  is  a  chronic  deficit  in  the  amount  of 
nitrogen  in  the  body — i,  e.,  a  wasting  of  the  bodily  albumen — require 
as  little  experimental  demonstration  as  does  the  contrary  proposition 
that  the  intestines  act  vicariously  in  digesting  and  absorbing  food 
where  the  bodily  weight  remains  constant  and  the  general  condition 
of  the  patient  keeps  good  in  spite  of  the  deficiency  of  the  gastric 
digestion.  Both  are  absolute  conclusions  from  the  determinations 
of  the  loss  and  gain  of  the  bodily  weight.  These  self-evident  rela- 
tions have  nevertheless  been  worked  out  experimentally.f  Of  far 
greater  interest  is  the  study  of  the  relation  of  the  urea  (i.  e.,  the  de- 
composed bodily  nitrogen)  to  the  chlorides  in  the  urine,  because 
both  factors  are  dependent  on  the  energy  of  the  HCl  secretion  in 
the  stomach.  But,  as  in  all  investigations  of  the  metabolism,  it  is 
self-evident  that  these  analyses  are  only  of  value  when  the  ingesta 
as  well  as  the  excreta  are  determined.  This  has  been  neglected  by 
Bouveret ;  %  consequently,  in  spite  of  the  fact  that  his  results  are 
based  upon  28  analyses  upon  two  patients  with  cancer  of  the  stomach, 
his  conclusion  is  not  free  from  objection,  namely,  that  the  relation  of 
the  chlorides  to  urea  in  cancer  of  the  stomach  with  absence  of  HCl 
is  less  than  the  normal — i.  e.,  is  less  than  2-3  and  may  sink  to  0'7. 
Laubenheimer,*  acting  upon  the  above  postulate,  has  shown  in  a 
careful  investigation  upon  5  cancerous  patients  that  the  disease  does 
not  necessarily  influence  the  excretion  of  the  chlorides,  and,  if  reten- 
tion of  the  chlorides  does  occur,  that  this  is  due  to  no  characteristic 
feature  of  the  metabolism  in  cancer  but  to  some  accidental  factors, 

*  [For  further  details  upon  the  blood  changes,  see  the  recently  published  text- 
books on  the  blood  by  Grawitz  and  by  Limbeck. — Ed.] 

t  Rommelaere.  Journ.  de  med.,  etc.,  de  Bruselles,  1883-1886.— Rawzier.  De 
la  diminution  de  I'uree  dans  le  cancer.  Paris.  1889  (contains  full  literature).— Fr, 
Miiller.  Zeitschr.  fiir  klin.  Med.,  Bd.  xvi,  S.  496.— Klemperer.  Berl.  klin.  Woch- 
enschr.,  1889,  No.  40. 

X  Bouveret.  Le  rapport  des  chlorures  urinaires  a  I'uree  dans  I'hypersecretion 
gastrique  et  le  cancer  de  restomac.     Revue  de  med.,  1891,  No.  7. 

*  Laubenheimer.  Ausscheidung  der  Chloride  bei  Carcinomatosen.  Zeitschr.  fiir 
klin.  Med.,  Bd.  xxi,  p.  535. 


DURATION   OP   GASTRIC   CANCER.  339 

like  the  retention  of  water,  etc.  Katz,*  without  making  such  ex- 
haustive analyses,  but  repeating  and  extending  Bouveret's  experi- 
ments upon  a  large  series  of  other  diseases,  has  also  ascertained  that 
in  diseases  of  the  stomach  the  chloride  excretion  depends  upon  the 
general  metabolism,  and  the  relation  between  urea  and  the  urinary 
chlorides  is  abnormally  high  where  there  is  an  exudation  or  reten- 
tion of  fluid  in  the  bodily  cavities  or  in  the  tissues.  As  might  have 
been  anticipated,  this  shatters  forever  the  hope  that  specific  pathog- 
nomonic signs  might  be  obtained  from  such  variable  factors  as-  the 
changes  in  the  metabolism.  According  to  Kommelaere,  10  to  12 
grammes  of  urea  ought  to  be  the  highest  amounts  excreted  in  can- 
cer. But,  as  was  evident  a  priori, -this  hypazoturia  by  itself  has 
no  significance.f 

As  a  rule,  the  course  of  cancer  is  progressive,  irresistible,  and 
advancing  toward  a  fatal  termination.  Occasionally,  longer  or 
shorter  periods  may  occur  in  which  the  process  seems  to  stand  still, 
in  fact  even  to  retrograde.  Such  occurrences  may  lead  to  diag- 
nostic errors  and  doubts.  Such  periods  of  apparent  improvement  I 
have  repeatedly  observed.  Most  experienced  physicians  know  of 
them;  they  certainly  occur  much  more  frequently  than  the  text- 
books would  lead  us  to  suppose. 

The  duration  of  the  disease  may  vary  from  between  three  to  six 
months  to  two,  three,  or  more  years ;  on  an  average  it  lasts  between 
six  and  fifteen  months ;  a  shorter  course  is  at  all  events  exceptional. 
It  always  terminates  fatally.  Cases  of  cured  cancer  of  the  stomach 
have  been  repeatedly  reported,  yet  they  have  never  been  positively 
proved.  The  cases  reported  by  Dittrich,  Lebert,  Friedreich,  and 
others,  may  have  been  mistaken  for  gastric  ulcers  or  the  superficial 
cicatrices  which  have  already  been  described.  Thus,  in  one  of  my 
cases  of  cancer  of  the  breast,  I  found  in  the  stomach  a  radiating 
cicatrix  with  thick,  callous  edges  and  a  marked  atrophy  of  the  mu- 
cous membrane  in  the  vicinity.     It  would  have  been  reasonable  to 

*  Katz.  Ueber  die  Beziehungen  der  Chlorausscheidung  zu  Erkrankungen  des 
Magens.     Internat.  klin.  Rundschau,  1892,  No.  10. 

f  Grasset.  Nouveaux  elements  de  diagnostic,  differential,  etc.  Gaz.  hebdom., 
May  10,  1889. — Dujardin-Beaumetz,  loc.  cit. 


340  DISEASES  OF  THE  STOMACH. 

suppose  that  this  was  a  healed  primary  carcinoma  of  the  stomach 
with  metastases  in  the  mammary  gland.  But  the  microscope  showed 
just  the  reverse.  The  base  of  the  scar  was  formed  by  firm,  dense 
connective  tissue,  while  in  the  immediate  vicinity  of  the  border  in 
the  submucosa  scattered  cell -nests  were  found ;  these  could  only  be 
regarded  as  the  beginning  of  a  cancerous  process.  The  process 
was  thus  a  cancer  which  had  developed  in  the  cicatrix  left  after 
the  healing  of  an  ulcer.  The  opinion  that  this  was  a  cicatrized 
carcinoma  was  also  excluded,  because  such  an  abrupt  transi- 
tion from  purely  fibrous  tissue  to  recent  carcinomatous  prolifer- 
ation as  was  present  in  this  case  is  never  found  in  a  cancerous 
cicatrix. 

Frequency  of  Various  Symptoms. — The  above  clinical  picture  is 
only  schematic,  and  in  an  individual  case  numerous  modifications 
may  occur.  Writers  have  taken  great  pains  to  determine  the  rela- 
tive frequency  of  the  occurrence  of  the  various  symptoms,  and  in 
the  works  of  Brinton  and  Lebert  you  will  find  analyses  carefully 
prepared  from  relatively  large  numbers  of  cases.  In  practice — i.  e., 
in  the  diagnosis  of  a  suspected  case — such  statistics  have  only  a  rela- 
tive value,  and  are  more  interesting  for  the  nosology  of  the  disease. 
If  we  remember  our  statistics  never  so  well,  who  will  guarantee  that 
a  given  case  is  the  rule  or  an  exception  ? 

To  illustrate  the  above,  I  present  the  accompanying  half -sche- 
matic drawing  (Fig.  42)  of  a  case  in  which  a  colloid  cancer  involved 
the  lesser  curvature,  and,  being  partially  covered  by  the  left  lobe 
of  the  liver,  could  not  be  palpated  during  life.  The  patient  was  a 
tailor,  forty-eight  years  old,  who  had  never  complained  of  pain,  and 
had  never  had  haematemesis.  A  probable  diagnosis  of  cancer  of 
the  stomach  had  been  made  at  the  clinic  of  Prof.  Frerichs,  solely 
upon  the  marked  anorexia  and  the  progressive  cachexia,  and  by  the 
careful  exclusion  of  other  diseases.  The  fact  that  hsematemesis 
occurs  in  42  per  cent  (according  to  Lebert,  in  only  12  per  cent)  of 
the  cases,  and  that  a  tumor  is  absent  in  20  per  cent,  would  have  de- 
cided this  case  neither  positively  nor  negatively. 

For  the  sake  of  completeness,  however,  and  because  it  may 
nevertheless  be  of  some  assistance,  I  shall  not  withhold  the  fol- 
lowing figures.      They  are  based  upon  an   analysis    of   250   cases 


CANCER  OP  THE  STOMACH. 


341 


Fig.  42.-Colloid  cancer  of  lesser  curvature  of  stomacn. 


342  DISEASES  OF  THE  STOMACH. 

reported  by  Brinton  and  88  and  14:5  cases  respectively  collected 
by  Lebert,* 

Loss  of  appetite  occurs  in  45  per  cent ;  often  is  observed  only 
toward  the  close  of  the  disease ;  rarely  the  appetite  is  increased. 

Pain  is  present  in  92  per  cent  (Lebert,  75  per  cent).  It  is  fre- 
quently absent  in  old  people.  Brinton  claims  that  pain  between  the 
scapulae  indicates  a  cancer  on  the  lesser  curvature.  In  the  case 
which  I  have  just  cited  there  was  no  reference  to  such  an  interscap- 
ular pain,  and  my  own  experience  leads  me  to  consider  that  the  sig- 
nificance of  this  symptom  has  been  exaggerated. 

Vomiting  occurs  in  88  per  cent  (Lebert,  80  per  cent).  It  is 
most  frequent  where  the  orifices  are  involved.  ^Nevertheless,  a 
marked  stenosis  of  the  pylorus  may  exist  without  the  occurrence  of 
vomiting.  While  in  most  cases  it  occurs  a  considerable  time  after 
the  meal  (one,  two,  or  three  hours),  yet  it  may  take  place  much 
sooner,  and  in  drunkards  and  very  debilitated  persons  may  even  be 
present  in  the  morning  when  the  stomach  is  empty.  There  is  thus 
nothing  typical  in  the  time  of  its  occurrence. 

Hcematemesis  is  noted  in  42  per  cent  of  Brinton's  cases.  Lebert 
distinguishes  large  hsemorrhages  from  the  stomach  from  true  me- 
Isena  or  melanemesis  [the  vomiting  of  black  altered  blood]  ;  the  fre- 
quency of  the  former  he  estimates  at  only  12  per  cent. 

A  tumor  is  present  in  80  per  cent  of  the  cases,  according  to 
both  Brinton  and  Lebert.  It  is  seldom  palpable  before  the  third  to 
the  sixth  month ;  usually  it  is  only  distinct  in  the  second  half  of 
the  course  of  the  disease,  or  during  the  last  months  of  the  patient's 
hfe. 

The  towels  remain  regular  in  only  4  to  5  per  cent  of  the  cases. 
In  the  vast  majority  there  is  constipation,  or  constipation  alternat- 
ing with  diarrhoea ;  the  latter  is  a  manifestation  of  a  catarrhal  con- 
dition of  the  intestinal  mucous  membrane,  due  to  the  irritation  of 
hard  fecal  masses,  or  of  products  of  decomposition  which  have 
not  been  carried  off.  A  gastro-intestinal  fistula  may  be  formed, 
and  fseces  and  gases  may  reach  the  stomach,  or  the  stools  may 

*  A.  Ott  (Zur  Pathologie  des  Magencarcinoms,  Inaug.  Dissert.,  Zurich,  1867)  has 
added  33  additional  cases  from  Prof.  Biermer's  clinic,  and  has  obtained  substan- 
tially the  same  results. 


DIAGNOSIS  OF  GASTRIC   CANCER.  343 

become  lienteric — i.  e.,  the  presence  of  undigested  food  in  the 
fasces.  Yet  Rampold  *  has  observed  a  communication  between 
the  stomach  and  transverse  colon  and  an  adjacent  loop  of  intestine 
in  a  patient  sixty-six  years  of  age,  who  gave  no  definite  symptoms 
indicating  a  gastric  lesion ;  it  must  be  noted,  however,  that  the 
patient  also  suffered  from  dementia  paralytica,  Murchison  f  has 
called  attention  to  the  fact  that  stercoraceous  vomiting  will  be 
absent  when  the  contents  of  the  stomach  pass  directly  into  the 
colon,  since  there  can  be  no  formation  of  faeces.  Finally,  we  must 
mention  one  peculiarity  which  is  observed  where  the  orifices  of  the 
stomach  are  involved  by  the  cancer — i.  e.,  the  breaking  down  of 
the  new  tissue  may  cause  the  symptoms  due  to  the  stenosis  to  dis- 
appear, and  thus,  at  times,  an  improvement  may  seem  to  have 
occurred. 

Diagnosis. — Although,  taking  all  in  all,  the  diagnosis  of  the  dis- 
ease may  be  made  from  what  has  already  been  stated  concerning  the 
development,  course,  and  general  symptomatology,  yet  there  still 
remain  certain  important  diagnostic  features  the  consideration  of 
which  I  must  not  omit.  I  shall  begin  with  the  one  which  is  of  most 
recent  origin,  and  which  has  given  rise  to  somewhat  too  precipitate 
and  exaggerated  hopes.     I  refer  to — 

1.  The  absence  of  free  hydrochloric  acid  in  the  stomach  contents. 
It  was  a  great  triumph  of  Prof.  Kussmaul's  clinic  to  have  first 
methodically  investigated  the  subject.  The  opinion  was  originally 
expressed  by  R.  von  den  Velden,;};  that  cancer  of  the  pylorus,  ac- 
companied by  dilatation  of  the  stomach,  leads  to  a  suppression  of 
the  secretion  of  hydrochloric  acid.  This  view  was  soon  indiscrim- 
inately applied  to  all  varieties  of  cancers  of  the  stomach.  But  even 
the  combined  labors  of  numerous  investigators,  and,  not  the  least, 
those  of  the  above-mentioned  clinic,  have  shown  that  this  statement 
can  not  be  maintained  in  its  entirety ;  yet  it  has  led  to  results  of 
great  diagnostic  and  therapeutic  significance. 

But  historical  justice  demands  that  we  think  of  an  investigator 

*  Rampold.     Hiifeland's  Journal,  5te  Stiick,  1886. 
f  Quoted  by  Henoch.    Klinik  der  Unterleibskrankheiten.     Berlin,  1863. 
X  Von  den  Velden.    Ueber  Vorkommen  und  Mangel  der  freien  Salzsaure  im 
Magensaft.    Zeitschr.  fiir  klin.  Med.,  Bd.  xxiii,  p.  369. 
23 


344  DISEASES  OF  THE  STOMACH. 

who,  years  ago,  so  thoroughly  studied  the  question  of  the  occurrence 
of  hydrochloric  acid  in  gastric  cancer  that  the  knowledge  of  his 
conclusions  would  have  spared  us  much  needless  discussion.  Ee- 
markahly,  however,  his  lahors,  splendid  for  the  age  in  which  he 
lived,  have  so  absolutely  passed  into  oblivion  that  even  his  own 
countrymen  nowhere  speak  of  them.  Golding  Bird,  Physician  to 
the  Islington  Dispensary,  and  Professor  of  Medicine  at  Guy's  Hos- 
pital in  London,  in  1842,*  in  a  man  forty -two  years  old,  with  pyloric 
cancer  and  dilatation  (verified  by  autopsy),  determined  the  relation 
of  hydrochloric  and  the  organic  acids  in  a  series  of  examinations 
of  the  vomit,  the  methods  employed  being  faultless  even  to-day.f 
In  about  three  weeks  three  estimations  were  made,  the  results  of 
which  led  Bird  to  conclude  that  "  during  the  more  irritative  stage 
of  the  disease  free  hydrochloric  acid  is  present  in  the  vomit  in  con- 
siderable quantities,  but  it  gradually  diminishes  in  proportion  to  the 
patient's  loss  of  strength ;  and  that  the  organic  acids  increase  pro- 
portionally as  the  free  hydrochloric  acid  diminishes."  It  is  worthy 
of  note  that,  by  a  control  experiment  on  a  healthy  subject  (an  emetic 
dose  of  sulphate  of  zinc  was  given  thirty  minutes  after  a  moderate 
dinner),  free  hydrochloric  acid,  but  only  a  very  small  quantity  of 
organic  acids,  could  be  demonstrated  ;  another  experiment,  on  a 
patient  with  cancer  of  the  liver  and  dilatation  of  the  stomach  result- 
ing from  pressure  of  the  tumor  on  the  pylorus,  showed  a  somewhat 
lessened  amount  of  free  hydrochloric  acid  but  large  amounts  of  com- 
bined hydrochloric  and  organic  acids. 

In  these  investigations  it  may  be  possible  that  a  little  confusion 
may  exist  in  the  relation  of  the  free  to  the  combined  hydrochloric 
acid  and  the  organic  acids,  because  the  diet  and  the  time  of  the 
emesis  were  not  precisely  determined  ;  yet  Bird's  deductions  are  not 
to  be  questioned,  and  are  of  great  importance.  Bird  himself  was 
conscious  of  this,  but  complains  of  the  amount  of  time  demanded 
by  these  studies,  and  it  seems  he  did  not  pursue  them  further.     In 


*  Golding  Bird.  Contributions  to  the  Chemical  Pathology  of  some  Forms  of 
Morbid  Digestion.     London  Med.  Gazette,  1842.  vol.  ii,  p.  391. 

f  Distillation  of  the  volatile  acids,  incineration  of  the  residue,  boiling  with 
dilute  nitric  acid,  and  estimating  the  silver  salt  with  and  without  the  addition  of 
soda. 


DIAGNOSIS  OF   GASTRIC   CANCER.  345 

this  way  they  passed  into  obscurity,  and  it  was  only  recently  that 
this  subject  was  again  taken  up,  but  with  new  methods. 

The  subject  has  been  most  thoroughly  investigated  by  a  large 
number  of  physicians.  To  show  the  extent  of  this  discussion  I  need 
merely  mention  in  chronological  order  the  names  of  Yon  den  Yel- 
den,  Ewald,  Kietz,  Thiersch,  Eiegel,  Kahn  and  Yon  Mering,  Ja- 
worski  and  Gluczynski,  Bamberger,  Kraus,  Dreschfeld,  Eosenbach, 
Krukenberg,  Rosenheim,  and  many  others.  Unquestionably  the 
largest  amount  of  material  was  collected  by  Eiegel,  who  reported 
sixteen  cases  of  cancer  of  the  stomach,  in  which  three  hundred  and 
six  separate  examinations  were  made.*  It  will  be  superfluous  to 
follow  the  views  expressed  jpro  and  con  by  the  various  writers,  espe- 
cially since  it  has  now  been  definitely  settled  that  the  absence  of  HGl 
i/n  cancer  of  the  stomach  has  no  special  significance  as  such,  hut  has 
only  the  value  of  a  secondary  symptom.  It  can  very  well  be  main- 
tained, as  I  have  always  done,  that  carcinoma  regarded  as  a  histo- 
logical neoplasm  in  no  way  lessens  or  destroys  the  secretion  of  hy- 
drochloric acid.  This  has  recently  received  additional  and  almost 
superfluous  corroboration  by  the  unearthing  of  Bird's  researches. 
But,  whatever  view  is  taken,  it  would  nevertheless  be  a  valuable  di- 
agnostic criterion,  provided  other  complicating  factors  did  not  inter- 
fere with  the  determination  of  the  presence  of  hydrochloric  acid — 
but  not  of  its  secretion.  Each  is  correct.  When  the  new  growth 
is  confined  microscopically  and  macroscopically  (which  by  no  means 
always  correspond)  to  a  limited  area,  when  the  accompanying  ca- 
tarrh of  the  mucous  membrane  is  moderate,  and  when  there  is  no 
atrophy,  then  the  secretion  of  hydrochloric  acid  may  remain  ample 
till  it  disappears  with  the  approach  of  death ;  or  it  may  be  much 
diminished,  as  occurs  in  all  cachetic  conditions.  Indeed,  as  has  been 
specially  urged  by  Eosenheim,f  if  the  cancer  has  developed  in  the 
scar  of  an  ulcer,  there  may  be  normal  or  increased  amount  of  HCl 
at  the  beginning  of  the  disease.  [A  number  of  such  cases  has  been 
reported  in  which  the  presence  of  free  HCl  persisted  almost  to  the 
end  of  the  disease.]     However,  in  the  vast  majority  of  cases  one  of 

*  Riegel.     Zeitschr.  fiir  klin.  Med.,  Bd.  xii,  p.  430. 

f  Rosenheim.  Zur  Kenntniss  des  mit  Krebs  compiicirten  runden  Magenge- 
schwurs.    Zeitschr.  fiir  klin.  Med.,  Bd.  xvii,  p.  116. 


346  DISEASES  OP  THE  STOMACH. 

the  above-mentioned  factors  plays  a  prominent  part,  and  the  secre- 
tion of  hydrochloric  acid  is  either  entirely  annihilated  or  is  reduced 
to  so  small  a  quantity  as  not  to  be  demonstrable  with  the  ordinary 
tests. 

This  would  afford  us  an  exceedingly  good  diagnostic  criterion 
but  for  the  fact — be  it  said  with  regret — that  a  diminution  in  this 
secretion  may  occur  in  other  pathological  conditions  of  the  gastric 
mucosa.  This  I  have  demonstrated  both  as  to  the  free  and  the  com- 
bined HCl.*  These  include  atrophy  and  amyloid  degeneration  of 
the  mucous  membrane  ;  self-evidently,  poisoning  or  corrosion,  in 
which  a  large  portion  of  the  mucous  hning  is  destroyed ;  mucous 
catarrhs  and  certain  neuroses  depending  upon  or  associated  with  a 
disturbance  of  the  innervation  of  the  gastric  glands.  It  is  manifest, 
as  I  have  already  stated,  that  acute  injuries  of  the  gastric  mucosa, 
poisoning,  and  acute  indigestion  may  cause  a  loss  of  glandular  ac- 
tivity, just  as  in  an  acute  catarrh  of  the  kidney  there  is  a  marked 
diminution  of  its  secretion,  or  as  an  injection  of  atropine  into  Whar- 
ton's duct  dries  up  the  salivary  secretion.  Likewise,  in  my  own  per- 
son 1  found  that  the  stomach  contents  were  absolutely  free  from 
hydrochloric  acid  during  a  very  transitory  nicotine  poisoning ;  on 
another  occasion,  during  a  sea  voyage,  I  could  obtain  no  reaction 
with  Congo  paper  in  the  food  which  was  vomited  one  hour  after 
breakfast.  Such  conditions  are  only  of  short  duration,  and  rapidly 
disappear  after  the  removal  of  the  irritant  or  under  a  suitable  diet. 
The  experiments  of  Wolfram  f  show  that,  while  fever  is  present  in 
all  the  acute  infectious  diseases,  the  gastric  juice  contains  no  hydro- 
chloric acid  and  exerts  no  digestive  action  either  within  or  outside 
of  the  organism.  We  also  know  concerning  certain  chronic  dis- 
eases-— for  example,  Addison's  disease,  pernicious  anaemia,  many 
cases  of  pulmonary  phthisis,  valvular  diseases  of  the  heart,  diabetes, 
3tc. — that  the  secretion  of  hydrochloric  acid  is  reduced  to  a  mini- 
num,  and  no  free  acid  can  any  longer  be  detected. 

But  even  physiologically  there  are  very  marked  variations  in  the 


*  Ewald.  Ueber  Strieturen  der  Speiserohre,  Zeitschr.  fiir  klin.  Med.,  Bd.  xx, 
p.  562. 

f  Announced  by  Gluczynski.  Ueber  das  Verhalten  des  Magensaftes  in  fieber- 
haften  Krankheiten.     Deutsches  Arch,  fiir  klin.  Med.,  Bd.  xxxiii. 


DIAGNOSIS  OP  GASTRIC   CANCER.  347 

amount  of  acid  produced.  Normally,  the  amount  of  HCl  secreted 
is  regulated  by  the  amount  and  kind  of  food,  so  that  some  free  HCl 
is  soon  present.  This  does  not  occur  in  the  vast  majority  of  cases 
of  cancer  of  the  stomach.  But  this  does  not  depend  upon  some  in- 
fluence of  the  cancer  on  the  production  of  HCl,  but  is  simply  due 
to  the  accompanying  catarrhal,  inflammatory,  or  atrophic  conditions 
of  the  fi-astric  mucous  membrane.  If  these  are  absent  the  acid  is 
secreted  abundantly,  as  in  the  case  reported  by  Bird,  another  by 
Cahn,  and  still  another  reported  later  which  had  been  observed  by 
Von  den  Yelden,*  or  there  may  even  be  an  excess  of  HCl  as  occurs 
in  the  cases  of  carcinomatous  degeneration  of  gastric  ulcers.f  But 
if,  during  our  observation  of  such  a  patient,  one  of  the  above  pro- 
cesses involves  the  gastric  mucous  membrane  and  becomes  more 
marked,  or  if  the  organism  gradually  becomes  weaker  and  weaker, 
as  the  result  of  the  carcinomatous  intoxication,  then  the  transition 
from  the  occurrence  of  hydrochloric  acid  to  its  absence  may  take 
place  in  a  relatively  short  space  of  time.  In  this  way  I  explain 
Bird's  case,  and  also  one  which  came  under  my  own  obser- 
vation : 

Mr.  R.,  merchant,  forty-two  years  old,  was  seen  in  consultation  on 
January  7th.  He  had  suffered  for  a  long  time  from  "chronic  catarrh," 
and  had  complained  of  a  severe  burning  sensation  in  the  stomach  for 
several  months.  He  was  admitted  to  the  Augusta  Hospital,  and  while 
there  was  treated  with  the  stomach  tube  and  was  very  much  benefited  by 
it.  He  learned  to  wash  out  his  stomach  and  did  it  frequently,  especially 
as  he  sought  in  this  way  to  remedy  his  frequent  dietetic  errors. 

The  patient  was  a  haggard  man,  with  a  dry  skin  and  retracted  abdo- 
men ;  he  lay  in  bed  on  account  of  weakness.  Heart  and  lungs  negative. 
There  was  a  small  movable  tumor  at  the  pylorus  about  the  size  of  a  wal- 
nut, slightly  tender  on  pressure.  No  succussion  sound.  The  stomach 
when  distended  reached  to  the  umbilicus,  causing  the  tumor  to  move 
downward  and  somewhat  to  the  right.  During  the  introduction  of  the 
tube  by  himself  he  vomited  slimy,  yellowish-green,  offensive  masses  of 
neutral  reaction  ;  accordingly,  no  free  acid  was  present.  No  glandular 
swellings.     Urine  clear  and  acid.     Stools  irregular. 

The  stomach  contents,  after  taking  the  test-breakfast  on  the  following 
morning,  undoubtedly  contained  a  considerable  amount  of  hydrochloric 

*  Cahn.  Verhandhmgen  des  vi.  Congress,  fiir  innere  Medicin,  1887,  S.  362 
und  373, 

f  Thus,  for  example,  Waetzhold  (Charite  Annalen,  Bd.  ix)  has  reported  a  ease 
with  3  per  mille  HCl.  In  the  two  cases  of  Rosenheim  the  amount  of  HCl  was  3-9 
and  3"4  per  mille. 


348  DISEASES  OP  THE  STOMACH. 

acid,  and  small  quantities  of  lactic  acid,  peptone,  and  propeptone.  The 
stomach  contents  digested  slowly. 

In  view  of  the  presence  of  hydrochloric  acid,  a  diagnosis  was  made  of 
a  non-carcinomatous  hypertrophy  of  the  pylorus  (cicatrization  of  an  old 
ulcer  ;  muscular  hypertrophy  accompanying  a  chronic  catarrh  (?) ). 

But  on  the  following  day  the  patient  vomited  bloody  masses,  and  com- 
plained of  severe  burning  pain  in  the  stomach  and  an  almost  intolerable 
dryness  of  the  mouth,  pharynx,  and  oesophagus.  Vomiting  recurred  very 
frequently  during  the  next  three  weeks  in  spite  of  a  rigorous  diet  and 
regular  lavage  of  the  stomach.  Each  time  the  stomach  contents  were 
abundant,  of  a  bloody  color,  or  contained  broken-down  coagula  ;  frag- 
ments of  food  were  also  present.  Hydrochloric  acid  was  never  found  ;  on 
the  other  hand,  large  quantities  of  yeast-cells,  bacteria,  and  mucus  could 
be  seen.  The  reaction  was  usually  neutral ;  if  acid,  it  was  due  to  acid 
salts  or  lactic  acid.  On  two  different  occasions  the  test  breakfast  was 
given  lege  artis,  and  each  time  the  absence  of  hydrochloric  acid  was 
noted.  The  tumor  remained  unchanged  and  could  be  felt  more  or  less 
distinctly,  according  to  the  fullness  of  the  stomach.  The  patient  suffered 
intensely,  lost  strength  rapidly,  and  urgently  wished  the  removal  of  the 
tumor  by  operation.  In  view  of  the  large  quantities  of  "  stomach  con- 
tents "  which  were  siphoned  through  the  tube  from  the  patient's  stomach 
—often  amounting  to  four  or  five  litres  [nine  to  eleven  pints] — dilatation 
of  the  stomach  was  diagnosed,  although  a  repetition  of  the  distention  of 
the  viscus  with  air  again  gave  no  positive  evidence  thereof.  I  could  not 
quite  explain  this  peculiar  condition,  but  I  expressed  to  my  colleagues  the 
suspicion  that  the  siphoned  fluid  came  from  the  intestines  rather  than 
from  the  stomach,  the  fluid  having  regurgitated  into  the  latter  through 
the  rigid  and  thus  incompetent  pylorus. 

At  the  patient's  request,  Prof.  Sonnenberg  resected  the  pylorus  on 
January  30th — i.  e.,  about  three  weeks  after  the  first  examination.  At 
and  surrounding  the  pylorus  was  a  hard  tumor,  .the  size  of  a  walnut, 
which  so  narrowed  the  orifice  that  the  tip  of  the  little  finger  could  be 
inserted  only  with  difficulty.  Several  glands  in  the  ligamentum  gastro- 
colicum  were  enlarged  to  the  size  of  cherries.  The  stomach  was  not 
dilated. 

After  the  operation  everything  went  smoothly,  and  for  the  first  few 
days  the  patient's  condition  was  excellent.  On  the  fourth  day  there  was 
a  slight  febrile  movement,  followed  by  marked  collapse  ;  the  patient  died 
on  the  evening  of  the  fifth  day.  At  the  autopsy  I  found  that  some  of  the 
sutures  (catgut  and  silk)  had  suppurated,  causing  a  localized  purulent  and 
adhesive  peritonitis  which  may  be  regarded  as  the  cause  of  death.  The 
mucous  membrane  in  the  line  of  sutures  was  hyfjersemic,  but  elsewhere 
teas  entirely  uninvolved.  On  the  other  hand,  the  muscularis  as  far  as 
the  fundus  was  infiltrated  and  thickened.  A  piece  of  the  fresh  tumor 
was  immediately  placed  in  absolute  alcohol,  which  was  subsequently  fre- 
quently changed  ;  microscopical  examination  showed  that  it  was  a  scir- 
rhous carcinoma  which  was  almost  entirely  limited  to  the  muscularis,  in- 
filtrating it  in  broad  bands.  The  greater  part  of  the  mucous  membrane 
ivas  entirely  normal,  or  at  most  only  slightly  infiltrated  by  an  interstitial 
proliferation  of  small  cells  from  the  submucosa.     In  places  there  was 


DIAGNOSIS  OF   GASTRIC   CANCER  3-t9 

more  atypical  growth  of  the  glandular  tubules,  and  cysts  of  various  sizes 
were  found  toward  and  in  the  subniucosa.  On  comparing  this  section 
luith  a  preparation  from  a  catarrhal  stomach  no  marked  differences 
could  he  found.  The  same  was  true  of  pieces  of  tissue  which  were  taken 
at  the  autopsy  from  the  fundal  and  cardiac  portions.  In  the  affected  area 
the  submucosa  was  sharply  defined  from  the  mucosa  on  the  one  side  and 
from  the  infiltrated  muscularis  on  the  other  ;  even  with  the  naked  eye  its 
wide-meshed  fibrous  structure  could  be  recognized. 

The  great  significance  of  this  case  is  manifest.  It  proves  that 
with  a  localized  cancer  and  an  intact  mucous  mernhrane  the  secre- 
tion of  hydrochloric  acid  may  continue  up  to  a  short  time  hefm^e 
death',  and  under  such  circumstances  conclusions  hased  upon  the 
demonstration  of  this  acid  may  he  erroneous.  The  hard  nodular 
character  of  the  cancer  precludes  the  possibility  of  an  antecedent 
ulcer  ;  so  that  Kosenheim  *  is  right  in  urging  that  the  presence  of 
free  HCl  does  not  of  itself  indicate  the  origiri  of  a  cancer  from  an 
ulcer,  but  that  other  symptoms  of  gastric  ulcer,  such  as  hfemate- 
mesis  (at  the  beginning  of  the  disease  !),  cardialgia  after  eating, 
localized  pain  in  the  epigastrium,  etc.,  must  have  been  present. 

Since  the  observation  of  this  case  a  number  of  careful  investiga- 
tions have  been  made  on  the  relations  of  hydrochloric  acid  to  cancer 
of  the  stomach  ;  of  these  I  shall  only  quote  the  following :  In  eight 
cases  of  this  disease  which  were  carefully  studied,  both  anatomically 
and  chemically,  Stienon  f  reports  that  four  gave  no  reaction  to  the 
color  tests,  while  the  other  four  gave  temporary,  more  or  less  posi- 
tive results.  In  fourteen  examinations  made  on  two  cases  with  the 
method  of  Cahn  and  Yon  Mering,  positive  reactions  were  obtained, 
the  amount  of  hydrochloric  acid  varying  between  0*4  and  2*3  per 
thousand,  but  the  color  tests  gave  a  negative  result  every  time.  The 
microscopic  examination  convinced  him  that  the  disease  is  fre- 
quently, if  not  usually,  accompanied  by  an  atrophy  of  the  glands, 
and  to  this  may  be  due  the  absence  of  hydrochloric  acid.  Similar 
conclusions  have  been  reached  by  Rosenheim  %  and  by  myself  in 

*  Loc.  cit.,  p.  135. 

*  L,  Stienon.  Le  sue  gastriqne  et  les  phenomenes  chimiques  de  la  digestion 
dans  les  maladies  de  Testomac.    Journal  de  Med.  de  Bruxelles,  October  5,  1888. 

f  Th.  Rosenheim.  Ueber  atrophische  Processe  in  der  Magenschleimhaut  in 
ihrer  Beziehung  zum  Carcinom  und  als  selbststandige  Erkrankung.  Berliner  klin. 
Woehenschr.,  1888,  No.  51-52. 


350  DISEASES  OF  THE  STOMACH. 

many  examinations  which  I  have  not  published.  It  is  to  be  noted, 
however,  that  such  atrophic  processes  are  not  the  general  rule,  be- 
cause  experience  teaches  us  that  the  accompanying  affection  of  the 
mucous  membrane  may  restrict  itself  to  a  more  or  less  extensive 
and  intense  inflammatory  process  (catarrh). 

2.  delations  of  the  Ferments. — For  the  other  ingredients  of  the 
gastric  juice,  the  pepsin  and  rennet  ferment  are  not  lessened  to  the 
same  degree  as  the  hydrochloric  acid.  The  products  of  the  action 
of  pepsin,  the  peptones,  are  found  almost  without  exception  even 
where  neither  free  hydrochloric  nor  lactic  acid  is  present.  Hence 
pepsin  must  have  been  secreted,  and  sufficient  free  HCl  to  form 
peptone  must  have  been  present  at  some  time.  The  majority  of 
these  filtered  stomach  contents  form  not  alone  propeptone  but  also 
true  peptone,  if  they  are  acidulated  to  about  two  per  thousand  of 
free  HCl.  Boas  {loo.  cit.)  claims  to  have  found  rennet  ferment  even 
where  free  HCl  was  absent.  The  explanation  of  this  apparent  para- 
dox lies  in  the  fact  that  the  secreted  HCl  combines  with  any  free 
bases,  weak  salts  and  albumen  and  its  derivatives,  while  the  fer- 
ments remain  free  ;  and  of  the  latter  we  know  that  their  action 
only  begins  to  be  lessened  when  the  products  of  fermentation  are 
present  in  excess.  The  relation  of  these  three  elements  [hydro- 
chloric acid,  pepsin,  and  rennet  ferment],  and  the  mode  of  deter- 
mining them,  will  therefore  depend  very  much  upon  the  nature  of 
the  food  and  the  energy  of  the  secretion — the  effects  of  the  variety 
and  extent  of  the  lesion  of  the  mucous  membrane  being  self-evi- 
dent. [JN'o  practical  diagnostic  results  have  thus  far  been  gained 
by  the  tests  for  the  gastric  ferments  in  cancer  of  the  stomach. 
Their  absence  is  only  indicative  of  atrophic  conditions  of  the  gastric 
mucosa.     See  page  6Y.] 

But  the  important  fact  remains  that  free  hydrochloric  acid  is 
usually  absent  in  carcinoma  of  the  stomach.  Unfortunately,  the 
diagnostic  value  of  this  circumstance  is  decidedly  affected  by  the 
occurrence  of  this  same  loss  in  the  other  conditions  which  I  have 
already  mentioned.  J5ut,  gromting  this,  the  proposition,  which  1 
was  thef/rst  to  announce,  is  still  true,  that  the  demonstration  of  the 
presence  of  hydrochloric  acid  points  with  very  great  probahility 
against  the  existence  of  cancer  of  the  stomach  ;  for  the  cases  of  this 


DIAGNOSIS  OF   GASTRIC  CANCER.  351 

disease  in  wliicli  there  is  a  positive  reaction  to  the  carefully  applied 
tests  are  so  rare  that  they  have  very  little  bearing  on  the  question.* 

Under  certain  conditions  (stagnation  of  the  ingesta  or  the  intro- 
duction of  easily  fermenting  food)  the  hydrochloric  acid  may  be  re- 
placed, or  may  be  accompanied  by  lactic  acid,  fatty  acids  and  their 
salts,  which  may  impart  an  acid  reaction  and  penetrating  odor  and 
taste  to  the  contents  of  the  stomach.  Of  especial  interest,  however, 
is  the  fact,  which  has  been  repeatedly  observed  in  this  disease,  as 
well  as  in  other  affections  of  the  stomach,  that,  with  an  absolute 
loss  of  the  hydrochloric-acid  reaction,  this  deficiency  in  the  digest- 
ive function  has  been  replaced  for  a  long  time  by  the  vicarious 
action  of  the  intestinal  digestion,  or  by  the  formation  of  large  quan- 
tities of  lactic  acid  (or  eventually  of  acetic  acid). 

[3.  Significance  of  Lactic  Acid. — Boas  was  the  first  to  lay  stress 
upon  the  fact  that,  in  most  cases  of  cancer  of  the  stomach,  lactic 
acid  is  formed  in  such  large  quantities  that  this  relation  may  be 
used  for  diagnostic  purposes,  especially  in  the  early  stages  of  the 
disease.f  Boas  urges  that  we  must  distinguish  between  the  forma- 
tion and  occurrence  of  lactic  acid.  The  acid  occurs  in  many  gastric 
disorders,  especially  since  it  is  taken  into  the  stomach  with  meat, 
bread,  milk,  etc.  On  the  other  hand,  it  is  formed  only  in  cancer. 
This  is  due  to  the  stagnation  of  the  stomach  contents  which  results 
from  the  very  early  and  increasing  infiltration  of  the  muscular 
layers  by  the  neoplasm,  combined  with  the  absence  of  HCl.  ]^o- 
where  else  than  in  cancer  do  these  two  factors  occur  more  often ; 
hence  the  value  of  the  test.  Unless  both  of  these  factors  are  present 
large  quantities  of  lactic  acid  will  not  be  formed.  Thus  we  do  not 
encounter  it  when  ulcer  undergoes  carcinomatous  degeneration. 
Furthermore,  the  test  is  of  value  only  from  a  positive  standpoint — 
i.  e.,  the  absence  of  lactic  acid  does  not  indicate  that  a  cancer  is 
necessarily  absent.  Hence  Boas  does  not  claim  that  it  is  of  service 
in  all  cases,  but  in  many  of  them  ;  and  especially  at  an  early  period. 


*  I  have  given  these  conclusions  exactly  as  they  were  stated  in  the  earlier  edition 
of  this  work.  Their  correctness  has  been  shown  by  all  researches  which  have  since 
been  published  on  this  subject. 

•j-  [This  relation  was  first  pointed  out  by  Cahn  and  Von  Mering. — Langguth. 
Boas's  Arch.,  Bd.  i,  p.  358.— Ed.] 


352  DISEASES  OP  THE  STOMACH. 

before  a  tumor  can  be  palpated  and  before  tlie  cachexia  lias  become 
pronounced — a  time,  in  otlier  words,  when  radical  measures  can 
best  be  carried  out.  (For  tlie  exact  details  of  the  tests,  see  pages 
41  and  54.) 

Boas's  claims  have  been  corroborated  by  a  number  of  wi'iters, 
among  whom  we  may  mention  Oppler,  Cohnheim,  Pariser,  Frieden- 
wald,  Hammerschlag,  Stewart,  Manges,  Schiile,  I)e  Jong,  and  others. 
Its  value  has  been  more  or  less  recognized,  but  its  claims  as  a  spe- 
cific denied  by  Riegel,  Thayer,  Rosenheim,  Klemperer,  Strauss,  Bial, 
Langguth,  and  others.  But  Boas  never  claimed  that  it  was  abso- 
lutely pathognomonic  of  cancer,  but  only  highly  suggestive  of 
this  disease  when  combined  with  other  symptoms ;  that  the  lactic 
acid  must  be  formed  in  large  quantities,  and  that  the  tests  should 
be  tried  several  times.  A  number  of  investigations  which  have 
since  been  pubhshed  proves  that  lactic  acid  may  be  formed  as  well 
as  occur  in  other  conditions  than  cancer,  which  are  accompanied  by 
motor  and  secretory  insufficiency  of  the  stomach.  Thus  Strauss  has 
reported  a  ease  of  fat  necrosis  of  the  pancreas,  and  Riegel  *  one  of 
invagination  of  the  colon,  in  which  large  quantities  of  lactic  acid 
were  found.  Still,  even  the  opponents  of  the  test  admit  that  large 
quantities  of  lactic  acid  occur  in  from  Y8  per  cent  (Rosenheim)  to 
91  per  cent  (Strauss)  of  cases  of  cancer  of  the  stomach. 

It  must  be  added  that  sometimes  instead  of  occurring  early  in 
the  disease  it  does  not  appear  till  later  on.]  f 

4.  The  presence  of  specific  tissue  elements  in  the  vomit,  or  in  the 
masses  raised  through  the  stomach  tube.  I  have  already  spoken  in 
general  of  the  constituents  of  the  vomit ;  here  I  need  only  recapitu- 
late that  in  the  advanced  stages  of  this  malady  we  may  find  a  very 
great  variety  of  fungi,  yeast-cells,  sarcinse,  bacteria,  pavement  and 
round  epithelial  cells,  with  large  nuclei,  single  nuclei,  and  nucleoli, 
and  large  masses  of  detritus  colored  brown  to  a  dark  green,  and 
mixed  with  all  kinds  of  remnants  of  food.    But  the  present  question 


*  [Quoted  by  Riegel,  op.  cit.,  p.  137. — Ed.] 

t  [The  German  literature  of  this  subject  may  be  found  in  Langguth.  Boas's 
Arch.,  Bd.  i,  p.  355.  De  Jong,  ibid..  Bd.  ii,  p.  53.  Hammerschlag,  ibid.,  Bd.  ii,  pp. 
1  and  198.  The  American  literature  is  given  by  Manges.  New  York  Medical 
Record,  April  27,  1895.— Ed.] 


DIAGNOSIS   OF   GASTRIC   CANCER.  353 

is,  Is  it  possible  to  recognize  specific  cancerous  tissue  ?  This  is  cer- 
tainly impossible  with  isolated  epithelial  cells.  It  must  be  admitted 
with  regret  that,  in  spite  of  all  the  time  and  labor  which  have  been 
expended,  no  means  have  yet  been  discovered  by  which  we  can  dis- 
tinguish specific  cancer  cells  from  the  ordinary  varieties  of  epithelial 
cells  found  in  the  stomach  contents,  some  of  which  are  derived  from 
the  walls  of  that  viscus,  while  others,  from  the  mouth  and  oesopha- 
gus, have  been  swallowed.  Even  Brinton  said :  "  But  mere  isolated 
cells  or  nuclei  scarcely  justify  a  decision,"  Lebert,  in  his  Physi- 
ologic pathologique,  pictures  cells  with  six  or  more  concentric 
layers,  which  he  considers  specific  cancer  cells,  "  globules  cancereux 
d  paroix  coiicentriquesy    These  cells  are  nothing  more  nor  less  than 


Fig.  43. — Cancerous  cell-nest  raised  through  stomach  tube. 
(From  Mr.  L.,  December  11,  188G.     Sketched  with  camera  lucida.) 

starch  granules.  For  my  part,  I  only  consider  conclusive  the  con- 
centrically stratified  aggregations  of  cells,  true  cancer  cell-nests,  such 
as  are  shown  in  Fig.  43.  In  the  case  from  which  this  specimen  was 
obtained  it  was  even  of  decisive  value. 

Mr.  L.,  about  thirty-five  years  old  ;  no  inherited  diseases ;  has  been 
complaining  for  the  last  six  months  of  anorexia,  pain  in  the  epigastrium, 
and  frequent  vomiting  ;  no  tumor  nor  cancerous  cachexia.  By  means  of 
the  stomach  tube  large  masses  of  mucus  were  obtained  every  time ;  hydro- 


364 


DISEASES  OP  THE  STOMACH. 


chloric  acid  could  never  be  demonstrated.  The  diagnosis  lay  between  a 
severe  mucous  catarrhal  gastritis  and  an  occiilt  neoplasm.  On  renewal  of 
the  examinations  faint  blood  streaks  were  seen,  and  a  small,  firm  particle 
was  obtained  ;  from  this  the  above  preparation  was  made.  By  its  means 
alone  the  diagnosis  was  established,  and  the  death  of  the  patient  about 
tw;o  months  later  verified  its  correctness. 

But  even  sucli  specimens  as  the  one  in  question  may  give  rise 
to  errors.  It  occasionally  happens  that  very  small  pieces  of  the  gas- 
tric mucosa  may  be  detached  where  the  membrane  is  very  vulnerable, 
even  when  a  cancerous  neoplasm  is  absent.  If  such  a  piece  is  placed 
on  a  slide,  the  pressure  of  the  cover-glass  may  cause  the  epithelium 

surrounding  an  excretory  duct  to 
assume  a  concentric  stratification 
closely  resembling  a  cancerous 
cell-nest.  The  drawing  of  such 
a  specimen  is  given  in  Fig.  44 ; 
it,  together  with  a  large  shred  of 
the  epithelial  lining  of  the  stom- 
ach, was  found  in  the  wash-water 
while  washing  the  stomach  of  a 
patient  twenty-eight  years  old, 
suffering  from  a  mucous  catarrhal 
gastritis,  with  no  symptoms  of 
cancer,  and  whose  improvement  was  continuous.  On  page  196  I 
have  already  given  similar  but  not  such  deceptive  figures. 

[Cohnheim  *  reports  five  cases  of  gastric  cancer  in  which  bits 
of  tumor  tissue  were  found  and  examined.] 

5.  The  cancerous  tumor.  Concerning  tumors  of  the  stomach,  I 
shall  only  remark,  in  passing,  that  it  is  self-evident  that  to  be  pal- 
pable they  must  be  situated  upon  the  greater  curvature,  or  at  the 
pylorus,  and  that  neoplasms  situated  upon  the  lesser  curvature  are 
beyond  the  reach  of  the  palpating  fingers,  especially  if  the  growth 
is  along  the  surface  and  is  overlapped  by  the  liver ;  such  a  condi- 
tion was  present  in  the  case  from  which  Fig.  42  was  taken ;  and, 
finally,  that  tumors  on  the  lesser  curvature  can  only  be  palpated 
when  the  stomach  occupies  an  abnormal  position.     It  is  equally  ob- 


FiG.  44. — A  piece  of  the  epithelial  covering 
of  the  mucous  membrane  of  the  stomach, 
resemblinc^  a  cancerous  cell-nest.  (From 
Mr.  K.,  March  10,  1887.  Sketched  with 
camera  lucida.) 


*  [Cohnheim.     Boas's  Archiv,  Bd.  i,  p.  294.— Ed.] 


DIAGNOSIS  OF  GASTRIC   CANCER.  355 

vious  that  the  palpation  of  gastric  tumors  may  be  rendered  impossi- 
ble by  the  development  of  ascites  from  any  cause.  For  a  long  time 
it  was  considered  an  axiom  that  movement  of  gastric  tumors  with 
respiration  became  possible  only  after  adhesions  had  been  contracted 
with  the  liver.  But  even  this  rule  is  not  without  exceptions.  I,  as 
well  as  Fr.  Miiller,  have  repeatedly  observed  distinct  respiratory 
movement  of  the  stomach,  which,  as  shown  by  autopsy,  was  totally 
carcinomatous,  without  any  adhesions  to  the  adjacent  viscera ;  and 
yet  which,  during  life,  descended  with  every  inspiration,  as  a  result 
of  the  flattening  of  the  diaphragm.  A  similar  movement  of  the 
tumor  may  be  transmitted  from  the  liver  when  the  neoplasm  lies 
close  to  the  edge  of  the  liver  without  the  formation  of  any  adhesions. 
At  the  Policlinic  I  have  repeatedly  and  carefully  examined  a  pa- 
tient with  such  a  tumor,  the  size  of  a  fist,  situated  on  the  greater 
curvature  near  the  pylorus ;  it  was  freely  movable  both  with  the 
fingers  and  by  distending  the  stomach  with  air ;  the  descent  with 
every  movement  of  inspiration  was  very  noticeable.  But  such  cases 
are  always  exceptional ;  and,  indeed,  their  occurrence  as  such  merely 
serves  to  strengthen  the  general  rule  above  stated. 

[The  present  views  as  to  the  respiratory  movement  of  gastric 
tumors  may  be  briefly  formulated  thus :  E^eoplasms  at  the  pylorus 
act  differently  than  those  situated  on  the  curvatures.  Pyloric  tumors 
move  with  respiration  only  after  they  have  contracted  adhesions  to 
the  liver.  Those  on  the  curvatures  are  movable,  as  a  rule,  at  all 
times.  A  feature  peculiar  to  them  has  been  pointed  out  by  Min- 
kowski,* that  their  ascent  with  expiration  may  be  retarded  by  fixing 
them ;  thus,  if  we  press  on  the  tumor  after  taking  a  full  inspiration, 
it  will  not  rise  until  the  pressure  is  released.  This  feature  is  of 
value  not  alone  in  distinguishing  gastric  from  other  tumors,  but 
also  in  distinguishing  those  on  the  curvatures  from  the  growths  at 
the  pylorus.] 

It  is  also  important  to  bear  in  mind  that  most  tumors  feel  much 
larger  to  the  palpating  fiiiger  than  they  really  are,  and  that  they 
may  change  their  position  according  to  the  fullness  of  the  stomach 
or  intestines.     In  like  manner  a  good  idea  of  the  size  and  situation, 

*  [Minkowski.    Berl.  klin.  Woehenschr.,  1888,  No.  31. — Boas,  op,  cit.,  Bd.  ii,  p. 
174.— Ed.] 


356  DISEASES  OF  THE  STOMACH. 

wlietlier  in  the  stomach  or  in  one  of  the  adjacent  viscera,  is  not  sel- 
dom only  obtainable  after  the  distention  of  the  stomach  or  intes- 
tines ;  at  times  it  may  be  necessary  to  examine  the  patient  not  alone 
while  recumbent,  but  also  by  depressing  the  head  deeply  and  elevat- 
ing the  pelvis,  or  in  the  knee-elbow  position.  To  distinguish  a  de- 
formity on  the  lower  border  of  the  liver,  especially  in  the  left  lobe, 
such  as  frequently  result  from  tight  lacing  in  women,  or  a  true 
tumor  of  the  hver,  pancreas,  or  spleen  from  a  new  growth  in  the 
stomach,  may  at  times  be  very  difficult ;  at  other  times  it  is  even 
impossible.*  The  reverse  may  also  occur,  and  a  carcinoma  of  the 
stomach  may  be  regarded  as  belonging  to  the  left  lobe  of  the  liver. 
Thus  Ott,t  after  giving  a  very  careful  description  of  such  a  case, 


The  complete  degeneration  of  the  entire  stomach  even  to  the  region 
of  the  hver,  the  rigid  infiltration  of  the  greater  curvature,  the  diminution 
in  size  and  contraction  of  the  organ  which  enabled  one  to  grasp  the 
greater  curvature,  and  which  caused  it  to  feel  like  the  edge  of  the  liver — 
all  of  these  factors  led  to  this  deception. 

It  is  equally  difficult  to  decide  whether  a  thickening  at  the  py- 
lorus is  due  to  hypertrophy  of  the  muscular  coat,  cirrhosis,  foreign 
body  encapsulated  in  the  stomach,:}:  wall -like  cicatrized  ulcer,  *  local- 
ized peritoneal  exudate,  or  carcinoma.  Carcinomata  of  the  omentum 
or  of  the  intestines,  which  may  be  lying  alongside  of  the  stomach, 
may  at  times  be  recognized  by  a  simple  distention  of  the  gut  with 
air.  Leube  very  properly  calls  attention  to  the  possibility  of  mis- 
taking the  pancreas  for  a  growing  tumor  of  the  stomach,  since  the 
progressive  emaciation  of  the  patient  permits  the  pancreas  to  be 
more  easily  palpated  through  the  relaxed  abdominal  wall.  It  is  very 
difficult,  and  at  times  even  impossible,  to  positively  differentiate  a 
pyloric  tumor  from  carcinoma  of  the  gall  bladder  or  even  gallstones 
which  have  not  been  accompanied  by  the  typical  symptoms  of  this 
condition — colic,  icterus,  hepatic  enlargement,  etc. — but  which  have 

*  [See  Osier,  op.  cit.,  Lecture  II,  for  an  instructive  series  of  cases  of  cancer  of 
the  stomach,  showing  the  various  diagnostic  features. — Ed.] 

t  Ott.    Zur  Pathologie  der  Magencarcinome.     Zurich,  1867,  S.  60. 
t  [See  p.  376.] 

*  Reinhard  (Inaug.  Dissert.,  Berlin,  1888)  has  collected  16  cases.  According  to 
my  experience  its  occurrence  must  be  much  more  frequent. 


DIAGNOSIS  OP  GASTRIC  CANCER.  357 

only  given  rise  to  a  vague  tumor  in  tlie  neighborhood  of  the  pylorus. 
Frequently  the  question  can  only  be  decided  after  prolonged  ob- 
servation by  the  eventual  growth  of  the  suspected  tumor,  the  occur- 
rence of  cancerous  cachexia,  the  formation  of  metastases,  and  swell- 
ings of  the  lymph  glands ;  but  sometimes  even  these  signs  may  fail, 
and  the  autopsy  alone  can  reveal  the  true  condition.  In  all  these 
cases  the  examination  of  the  stomach  contents  is  of  great  importance. 
K  the  usual  amount  of  free  hydrochloric  acid  is  found  after  the  test 
breakfast,  we  may  say  with  tolerable  certainty  that  the  stomach  is 
not  involved,  or  at  least  that  no  well-marked  cancer  is  present.  An 
excess  of  HCl  would  indicate  an  indurated  cicatrix  after  an  ulcer, 
the  possible  carcinomatous  degeneration  of  which  we  can  not  at 
once  determine  with  certainty. 

I  shall  relate  two  cases  to  illustrate  how  the  examinations  for 
HCl  established  the  diagnosis  beyond  a  doubt : 

On  November  24th  a  colleague,  Dr.  X.,  sent  to  me  Mrs.  W.,  thirty- 
three  years  old,  a  small,  emaciated  woman,  who  had  borne  four  children. 
She  complained  of  almost  continuous  pain  day  and  night  in  the  epigas- 
trium. The  pains  were  independent  of  eating,  had  lasted  more  than  six 
months,  and  were  temporarily  ameliorated  by  the  use  of  Carlsbad  water. 
The  patient  belched  frequently,  but  had  a  good  appetite,  and  had  never 
vomited. 

The  tongue  was  not  coated ;  the  abdomen  was  somewhat  pendulous, 
and  its  walls  relaxed.  Close  to  and  on  the  right  of  the  median  hne  was 
an  easily  movable  tumor,  which  was  painful  on  pressure ;  to  the  right 
and  external  to  this  was  a  second  tumor,  smaller,  and  descending  with 
inspiration  (gall  bladder).  Distention  of  the  stomach  with  air  revealed  a 
dilatation  and  a  descent  of  the  greater  curvature  to  midway  between  the 
symphysis  and  umbilicus.  The  stomach  contents  contained  an  abundance 
of  free  hydrochloric  acid,  but  no  products  of  fermentation  or  decomposi- 
tion. I'urther  questioning  revealed  that  the  patient  had  occasionally  suf- 
fered from  gastralgia.  Diagnosis :  Dilatation  of  the  stomach  resulting 
from  a  cicatricial  stenosis  of  the  pylorus,  and  hypertrophy  of  the  muscu- 
laris  as  a  sequel  of  an  ulcer  at  this  point.  The  proof  of  this  was  the  con- 
tinuous improvement  and  gain  in  strength  after  methodical  lavage  and 
suitable  diet.    No  cancerous  cachexia  was  present. 

The  diagnosis  of  this  case  was  possible  only  by  knowing  the 
result  of  the  examination  of  the  stomach  contents ;  and  having 
ascertained  this,  it  was  rendered  sufficiently  certain.  It  is  well 
known  that  a  hypertrophy  of  the  muscularis  in  the  pyloric  re- 
gion may  absolutely  simulate   a  neoplasm ;   as  examples,  I   refer 


358  DISEASES  OP  THE  STOMACH. 

to  tlie  case  reported  by  Yirchow,*  and  to  another  published  by 
myself :  f 

The  latter  case  was  as  follows  :  H.  S.,  fifty-six  years  old,  teacher  from 
Salzwedel.  The  man,  of  a  very  large  and  powerful  frame,  was  much 
emaciated  and  cachectic.  The  abdomen  was  relaxed  and  very  flaccid,  as  in 
a  multipara.  In  the  umbilical  region  close  to  the  surface  could  be  felt  a 
broad,  flat,  slightly  nodular  tumor,  which  reached  on  the  right  to  the 
axillary  line  and  on  the  left  to  the  parasternal  line.  Deep  inspiration 
gave  rise  to  a  feeling  of  false  movement — i.  e.,  the  sliding  of  the  abdominal 
wall  simulated  the  movement  of  a  tumor.  The  patient  was  very  dyspep- 
tic, suffered  severely  from  belching,  and  vomited  occasionally.  It  was 
self-evident  that  there  was  a  carcinoma  of  the  omentum  ;  the  only  ques- 
tion in  doubt  was  whether  there  was  also  a  cancer  of  the  stomach,  as  was 
indicated  by  the  dyspeptic  manifestations.  The  examination  of  the  stom- 
ach contents  revealed  an  abundance  of  free  hydrochloric  acid,  acidity  50  ; 
the  filtrate  had  a  digestive  action.  An  involvement  of  the  stomach  was 
thus  excluded.  The  correctness  of  this  diagnosis  was  verified  by  the 
autopsy. 

In  large  tumors  percussion  may  reveal  a  circumscribed  area  of 
dullness,  yet  it  is  hardly  necessary  for  me  to  state  that  'the  percus- 
sion note  will  vary  considerably  according  to  the  amount  of  air  in 
the  stomach  and  intestines,  and  according  to  the  force  used.  The 
best  results  are  obtained  by  very  delicate  direct  percussion  with  the 
finger,  or  by  auscultatory  percussion.;}:  Small  tumors  may  at  times 
be  inaccessible  to  both  percussion  and  palpation  by  a  twisting  of  the 
stomach  on  its  axis,  yet  they  may  be  rendered  demonstrable  by  in- 
flation of  the  stomach  or  intestines. 

At  times  the  tumor  may  pulsate  distinctly  when  it  lies  upon  the 
aorta  and  is  lifted  by  it.  This  pulsation,  which  may  be  very  marked, 
and  owing  to  the  retraction  of  the  abdominal  parietes  may  seem  to 
be  just  beneath  them,  is  distinguished  from  pulsation  of  the  aorta 
by  the  fact  that  a  tumor  only  expands  in  a  vertical  direction,  while 
the  aorta  does  so  both  vertically  and  laterally.  However,  this  does 
not  always  suffice ;  if  the  tumor  surrounds  the  aorta,  as  occurred  in 
Ott's  case,*  all  the  symptoms  of  an  aortic  aneurism  may  be  present : 

*  Virchow.     Wiener  med.  Wochenschr.,  1857,  No.  26. 
t  Ewald.     Berl.  kiln.  Wochenschr.,  1886,  No.  32. 

X  [The  phonendoscope  promises  to  be  very  useful  in  determining  delicate  dif- 
ferences of  this  kind.  My  experience  with  this  instrument  in  mapping  out  changes 
in  the  stomach  outlines  has  been  very  encouraging. — Ed.] 

#  Ott.    Loc.  cit,  p.  73. 


DIAGNOSIS  OF  GASTRIC  CANCER.  359 

transverse  and  vertical  pulsation,  systolic  bruit  and  distinct  thrill 
over  the  tumor,  smallness  of  the  femoral  arteries,  even  a  swelling  in 
the  back  may  be  present ;  we  may  sometimes  also  observe  symptoms 
which  are  exactly  similar  to  those  occurring  when  a  calcareous  an- 
nular infiltration  has  developed  in  the  walls  of  the  aorta  and  has 
caused  a  stenosis  of  the  vessel  and  a  dilatation  above  the  site  of  the 
stricture.  At  all  events,  a  differential  diagnosis  in  such  cases  is  out 
of  the  question. 

Hard  fecal  masses  in  the  transverse  colon  or  jejunum  may  simu- 
late a  tumor  ;  hence  the  rule.  Always  previously  evacuate  the  bow- 
els thoroughly  in  every  doubtful  case.  This  is  so  self-evident  that  I 
ought  scarcely  to  mention  it.  Yet  in  practice  I  find  that  this  point 
is  very  frequently  disregarded,  in  spite  of  the  fact  that  it  is  men- 
tioned in  every  text-book. 

In  many  cases  there  is  continuous  pain  at  the  site  of  the  neo- 
plasm ;  its  manifold  character  has  already  been  discussed  under  the 
general  symptoms.  In  other  cases  the  pain  varies,  at  times  ceasing 
entirely  or  being  simply  manifested  as  a  vague  burning  sensation  or 
oppression  in  the  epigastrium.  The  exacerbations  of  pain  are 
usually  due  to  fresh  inflammatory  processes  or  the  development  of 
new  tumors,  or  finally  to  traction  on  the  walls  of  the  stomach,  owing 
to  the  firm  adhesions  with  the  adjacent  movable  viscera.  Propaga- 
tion of  the  pain  downward  into  the  umbilical  and  suprapubic  regions 
renders  it  very  probable  that  the  neoplasm  is  advancing  along  the 
peritonseum  ;  occasionally  distinct  friction  sounds  may  be  heard,  es- 
pecially in  the  hepatic  region  ;  sometimes  a  rubbing  may  also  be  felt. 

6.  The  cancerous  cachexia.  The  peculiar  condition  of  patients 
with  cancer,  which  is  called  the  cancerous  cachexia,  appears  almost 
without  exception  sooner  or  later  in  the  course  of  the  disease,  and 
has  afforded  various  authors  an  opportunity  to  write  more  or 
less  poetical  descriptions.  Unfortunately,  this  condition  may  give 
rise  to  errors  both  positive  and  negative.  The  latter  are  due  to  the 
fact  that  it  is  usually  absent  at  the  beginning  or  during  the  first  half 
of  the  disease,  just  at  the  time  when  it  would  be  of  the  greatest 
service  to  render  a  diagnosis  certain. 

Some  time  ago  I  was  called  to  see  a  patient  in  whom  I  could  very 
easily  palpate  an  immense  nodular  tumor  occupying  the  entire  epigas- 
24 


360  DISEASES  OF  THE  STOMACH. 

trium,  and  also  adherent  to  the  liver.  The  patient  claimed  to  have  been 
well  up  to  two  weeks  before  my  visit  and  to  have  followed  his  usual  oc- 
cupation till  then  ;  also  that  neither  his  family  nor  his  friends  noticed  any- 
thing peculiar  about  him.  The  first  symptoms  observed  were  jaundice,  and 
oedema  of  the  lower  extremities,  which  appeared  suddenly.  Even  when 
I  saw  him  there  was  no  trace  of  a  true  cachexia,  and  yet  the  neoplasm  was 
evidently  of  long  standing. 

On  the  other  hand,  we  will  not  infrequently  see  persons  with  a 
typical  cancerous  cachexia,  and  whose  history,  as  well  as  the  results 
of  the  examination,  point  strongly  toward  cancer,  yet  after  a  longer 
or  shorter  course  of  treatment  they  recover  entirely,  and  thus  afford 
a  most  striking  proof  to  the  contrary.  Among  these  are  aged  per- 
sons with  chronic  catarrhal  gastritis  who  often,  especially  if  they 
were  formerly  plump,  emaciate  to  sucli  a  marked  degree  that  they 
look  as  if  they  had  cancer.  Disregarding  manifest  diseases  whose 
nature  may  be  discovered,  it  is  almost  superfluous  to  say  that  in  this 
class  of  patients  the  most  important  place  is  occupied  by  hysteria  in 
all  its  varieties.  Every  physician  knows  to  what  extent  the  emacia- 
tion and  loss  of  strength  of  hysterical  patients  may  sometimes  reach. 
Even  if  we  disregard  the  other  characteristic  symptoms  as  a  whole, 
it  will  be  observed  that  in  hysterical  cachexia  the  turgescence  of  the 
skin  is  well  preserved,  in  marked  contrast  with  the  condition  of 
the  skin  in  cancer  ;  this  is  a  valuable  diagnostic  sign.  The  differ- 
entiation is  rendered  still  more  difficult  in  the  hysteria  of  male 
subjects. 

Some  time  ago  I  was  associated  with  a  local  colleague  in  the  treatment 
of  a  man,  forty  years  old,  who  had  lost  thirty  pounds  in  two  months  ;  he 
had  quite  a  marked  but  not  extreme  cachexia,  and  a  variety  of  symptoms, 
among  which  were  complete  anorexia,  marked  fetor  of  the  breath,  and 
oppression  over  the  epigastriiim  ;  these  led  to  the  suspicion  of  a  rapidly 
growing  organic  lesion.  In  addition,  the  patient  also  suffered  from  pal- 
pitation of  the  heart  and  attacks  of  dyspnoea,  apparently  of  a  severe  form  ; 
he  also  had  strange  sensations,  especially  a  very  peculiar  and  annoying 
feeling  as  if  his  limbs  were  "dead  and  ice-cold."  Other  physicians  had 
expressed  an  unfavorable  prognosis,  and  this  had  not  failed  to  exert  a 
very  depressing  efPect  on  his  already  irritable  disposition.  He  lay  in  bed 
for  weeks  and  protested  that  he  was  unable  to  leave  it.  The  latter  symp- 
tom, the  cardiac  palpitation,  the  dyspnoea,  the  peculiar  sensations  for 
which  we  could  find  no  cause  either  in  the  circulatory  or  respiratory  sys- 
tem (there  was  a  moderate  dullness  on  the  right  side  posteriorly,  but  this 
proved  to  have  been  due  to  a  temporary  atelectasis) — all  these  led  us  to 
assume  the  presence  of  hysteria  complicated  with  a  very  severe  gastric 


DIAGNOSIS   OF   GASTRIC   CANCER.  361 

catarrh,  possibly  clue  indirectly  to  the  latter.  We  began  suitable  treat- 
ment, and  its  success  proved  the  correctness  of  our  supposition  ;  all  of  the 
symptoms  disappeared,  and  the  j)atient  was  discharged  cured,  after  four 
weeks'  treatment,  including  washing  out  the  stomach  with  a  watery  solu- 
tion of  thymol ;  the  other  drugs  used  were  hydrochloric  acid,  bromide  of 
potassium,  and  valerian. 

In  this  case  the  patient's  age  was  an  important  factor,  pointing 
against  the  presence  of  a  neoplasm.  But  here  also  very  remarkable 
sources  of  error  may  be  encountered. 

On  June  19.  1886,  a  physician  consulted  me  about  his  mother,  who  was 
a  little  over  fifty  years  old  ;  she  was  so  extremely  emaciated  and  feeble,  the 
skin  so  sallow  and  dry,  that  at  first  glance  she  looked  as  if  she  had  can- 
cerous cachexia.  She  had  severe  stomach  symj)toms,  especially  pain  after 
eating  ;  she  was  not  relieved  till  she  had  belched  repeatedly.  In  conse- 
quence of  this  she  kept  a  very  strict  and  innutritions  diet,  and  had  ema- 
ciated as  described  above.  On  closer  observation,  or  rather  waiting,  it 
became  evident  that  the  whole  trouble  was  hysteria.  She  suffered  from 
such  an  attack  of  belching  during  the  first  examination  ;  for  almost  half 
a  minute  the  gas  was  raised  with  a  rapid  succession  of  hiccoughs  and  with 
a  rumbling  noise  almost  like  thunder,  and  yet  the  abdomen  was  not  much 
distended.  This  was  frequently  repeated  at  short  intervals,  the  whole  at- 
tack giving  one  the  impression  of  a  brief  cyclone.  The  results  of  the  phys- 
ical and  chemical  examination  of  the  stomach  were  normal,  and  the  same 
was  true  of  the  stool,  as  was  ascertained  later. 

The  diagnosis  of  hysteria  had  naturally  been  already  made  by  other 
physicians,  and  the  entire  array  of  nervines  had  been  tried.  I  thought  of 
a  case  which  I  had  seen  long  ago  at  the  clinic  of  Prof.  Von  Frerichs,  in 
which  a  hysterical  spasm  of  the  glottis  i^romptly  ceased  whenever  the 
electrodes  wei'e  placed  upon  the  cervical  vagi  and  an  induced  cmrent 
passed  through  them.  This  expedient  was  similarly  successful  in  this 
case,  as  the  attack  ceased  instantly  on  applying  the  current.  But  as  I 
wished  to  effect  a  permanent  as  well  as  a  temporary  cure,  I  concluded  to 
wash  out  the  patient's  stomach  at  regular  intervals,  on  the  presumption 
that  the  mechanical  irritation  and  the  harsh  treatment  of  the  gastric  mu- 
cous membrane  would  thus  lessen  the  hypera^sthesia  of  the  organ.  I 
shall  leave  undecided  whether  this  presumption  was  correct  or  whether 
the  good  result  was  due  to  the  erratic  whim  of  a  hysterical  patient,  which 
has  so  frequently  contributed  to  the  success  of  what  seemed  to  be  the  most 
wonderful  remedies.  At  all  events,  these  troublesome  symptoms  disap- 
peared after  five  seances,  and,  according  to  a  recent  report,  have  never 
returned. 

Let  this  suffice  to  emphasize  once  more  the  fact,  which  is  already 
well  known,  that  the  cancerous  cachexia  regarded  alone,  and  as  the 
only  symptom,  is  of  doubtful  trastworthiness. 

Finally,  I  must  discuss  the  differential  diagnosis  in  so  far  as  it 


362  DISEASES  OF  THE  STOMACH. 

has  not  already  been  considered.  The  lesions  in  question  are  espe- 
cially gastric  ulcer,  severe  catarrhal  gastritis,  atrophy  of  and  amy- 
loid degeneration  of  the  mucous  membrane  of  the  stomach,  and 
marked  cases  of  hysteria  and  neurasthenia ;  and,  finally,  neighboring 
tumors,  especially  of  the  liver,  gall  bladder,  and  pancreas.  I  must 
premise  that  at  times  a  sharp  differentiation  of  these  conditions  may 
be  impossible  during  life  ;  in  other  cases  there  may  be  phases  in  the 
course  of  the  disease  in  which  every  factor  for  a  positive  diagnosis 
may  be  lacking.  At  all  events,  the  presence  or  absence  of  free  hy- 
drochloric acid  affords  a  degree  of  certainty  unattained  until  a  few 
years  ago.  That  it  is  not  always  absolute  I  have  already  endeavored 
to  impress  (see  page  346).  I  shall  merely  add  that  these  views 
which  were  originally  announced  by  me  have  since  been  generally 
adopted  by  the  profession. 

The  demonstration  of  the  presence  of  a  tumor  will  remain  as 
ever  the  most  important  and  decisive  feature.  Here  we  must  be 
careful  not  to  mistake  tumors  situated  outside  of  the  stomach,  or 
hypertrophic  tumorlike  thickening  at  the  pylorus,  gastroliths,  and 
similar  lesions  (see  pages  356  and  3Y6).  "Where  a  tumor  has  not 
been  demonstrated  the  diagnosis  may  be  only  relatively  certain ; 
thus  it  is  not  at  all  positive  in  atrophy  of  the  gastric  mucosa, 
which  may  completely  simulate  a  slowly  and  steadily  growing 
carcinoma  because  both  hydrochloric  acid  and  rennet  are  perma- 
nently absent.  The  absence  of  the  cancerous  cachexia  may  be  of 
importance,  since  it  appears  to  be  less  developed  in  atrophy.  But 
not  a  few  cases  have  been  reported  in  which  extensive  carcinoma- 
tous processes  ran  their  course  without  any  special  symptoms. 
Thus  Storer  *  reports  a  case  in  which  almost  the  entire  stomach 
underwent  colloid  degeneration  without  causing  any  marked  dis- 
turbances of  digestion  and  vomiting.  Sieweckef  has  collected 
twelve  similar  cases  in  which  the  characteristic  symj^toms  of  cancer 
were  absent  throughout. 

I  recently  had   an   opportunity  to  perform   an  autopsy  on  a  man, 
twenty-nine  years  old,  who  up  to  four  weeks  before  his  death  had  been 

*  Store!'.     Colloid  Disease  of  the  Entire  Stomach,  with  very  few  Symptoms. 
Boston  Med.  and  Surgical  Journal,  October  10.  1872. 

f  Siewecke.     Ueber  Magenkrebs.     Inaug.  Diss.     Berlin,  1868. 


DIAGNOSIS  OF  GASTRIC   CANCER.  363 

able  to  undergo  a  PI  ay  fair  [Weir  Mitchell]  treatment  for  a  supposed 
neurasthenia  without  disturbing  his  digestion  in  any  way.  Before  that 
time  an  abdominal  tumor  could  not  be  palpated  ;  later  a  haemorrhagic 
pleurisy  was  developed,  and  the  patient  died  in  coma.  I  found  a  general, 
widely  distributed  "  carcinomatous  "  condition.  The  stomach  was  imbedded 
in  nodular  masses,  its  walls  doubled  in  thickness,  its  diameter  about  that 
of  a  transverse  colon  of  medium  size.  The  microscope  showed  that  the 
mucosa  was  almost  entirely  infiltrated  with  a  fibro-sarcomatous  neoplasm ; 
only  in  small  areas  were  the  short  and  long  glandular  tubules  intact,  but 
the  epithelium  was  very  granular  and  cloudy,  and  the  contours  of  the 
cells  were  destroyed.  Stomach  digestion  had  undoubtedly  been  impos- 
sible long  before,  and  the  food  probably  passed  through  the  stomach  as  if 
it  were  a  prolongation  of  the  oesophagus  ;  the  intestines  had  been  able  to 
carry  on  this  severe  labor  of  digestion  up  to  a  short  time  before  death. 
Thus  the  case  may  be  added  to  those  already  cited,  where  the  nutritive 
processes  were  kept  up  although  the  digestive  functions  of  the  stomach 
had  been  entirely  lost,  and  the  whole  task  had  been  assumed  by  the 
intestines. 

In  this  category  must  also  be  placed  the  cases  in  which  the 
disease  is  occult  for  a  long  time,  or  is  only  manifested  by  vague 
dyspeptic  symptoms  ;  but  subsequently  to  or  apparently  because  of  a 
marked  change  in  the  metabolism,  great  worry,  or  a  very  different 
mode  of  life — i.  e.,  a  "  Schweninger  cure,"  or  an  exhausting  course 
of  treatment  at  a  mineral  spring — suddenly  the  entire  group  of 
symptoms  of  cancer  of  the  stomach  is  rapidly  developed.  The 
patients  imagine  that  they  have  discovered  the  cause  of  their 
ailment ;  while  the  truth  is,  that  the  change  of  the  metabolism 
has  simply  weakened  the  organism's  power  of  resistance  against 
the  neoplasm,  or,  in  other  words,  has  favored  the  growth  of  the 
carcinoma. 

The  differential  diagnosis  hetween  ulcer  and  cancer  of  the  stom- 
ach will  be  discussed  at  length  in  the  next  chapter.  Plere  I  shall 
simply  state  that  hydrochloric  acid  and  the  ferments  (pepsin  and 
rennet)  are  always  present  in  the  former,  but  are  absent  in  the 
great  majority  of  cases  of  the  latter.  Experience  has  shown  that 
an  ulcer  does  not  protect  a  patient  against  cancer,  but  it  seems  that 
if  the  latter  already  exists  the  former  is  never  added.  The  follow- 
ing may  serve  to  establish  the  diagnosis  : 

1.  The  appetite  in  cancer  is,  as  a  rule,  more  profoundly  and 
permanently  impaired.  In  ulcer  it  is  lost  only  during  the  exacer- 
bations, but  is  normal  in  the  remissions  and  intermissions,  although 


364  DISEASES  OP   THE  STOMACH. 

the  fear  of  causing  pain  makes  tlie  patients  eat  very  little.  As 
already  stated,  the  condition  of  the  tongue  is  quite  characteristic  : 
in  ulcer  it  is  usually  clean,  or  only  coated  at  the  base ;  in  cancer  it 
is  furred  in  the  great  majority  of  cases. 

2.  The  pain  is  generally  more  localized  in  ulcer,  and  is  usually 
limited  to  the  epigastric  region  and  the  left  parasternal  line.  Cor- 
responding to  the  frequency  of  the  situation  of  ulcer  on  the  poste- 
rior wall  of  the  stomach  (43  per  cent),  the  pain  very  frequently 
radiates  backward,  the  so-called  "  pain  in  the  small  of  the  back  " ; 
the  pain  is  usually  aggravated  or  caused  by  external  influences — 
taking  food,  pressure  from  without,  certain  bodily  movements  and 
postures,  and  sometimes  even  by  the  simple  act  of  breathing.  In 
cancer  it  is  usually  continuous,  less  intense,  and  not  occurring  in 
paroxysms.  Yet  the  most  manifold  variations  may  occur  in 
both. 

3.  In  ulcer,  vomiting  stands  in  an  undeniable  relation  to  the 
pain,  and,  like  it,  is  irregular  and  changeable ;  as  a  rule,  it  occurs 
at  an  early  stage  of  the  disease,  while  in  cancer  it  is  usually  absent 
during  the  first  few  months,  but  later  becomes  gradually  more 
frequent.  Ott  very  properly  says  that,  in  cancer,  vomiting  depends 
upon  the  site  of  the  tumor  ;  in  ulcer,  upon  the  intensity  and  dura- 
tion of  the  pain.  The  presence  of  characteristic  kinds  of  tissue  in 
the  vomit,  its  €idmixture  with  blood,  and  the  vomiting  of  pure 
blood,  have  all  been  discussed  under  the  symptoms.  I  shall  merely 
add  that  haemorrhage  is  relatively  and  absolutely  more  frequent 
in  ulcer ;  its  severity  is  also  more  marked  in  this  lesion.  On  the 
other  hand,  the  intervals  between  the  haemorrhages,  or  a  relatively 
brief  series  of  them,  are  much  longer  in  ulcer,  while  in  cancer, 
having  once  begun,  they  recur  more  frequently  or  permanently. 
If  one  is  called  to  a  patient  with  severe  haemorrhage  from  the 
mouth  and  anus,  which  has  occurred  suddenly,  and  has  been  so 
severe  that  there  is  danger  of  collapse  from  the  profound  anaemia, 
from  these  points  alone  one  may  make  a  diagnosis  of  ulcer  with 
reasonable  certainty. 

The  mistaking  of  the  so-called  essential  or  idiopathic  anaemia  for 
carcinoma,  or,  on  the  other  hand,  the  failure  to  recognize  a  cancer, 
probably  occurs  less  frequently  in  Germany  than  it  does  elsewhere. 


DIAGNOSIS  OP   GASTRIC  CANCER.  365 

At  least,  in  English  literature,  I  have  found  the  reports  of  quite 
a  number  of  such  cases  in  which  a  careful  examination  of  the 
blood  and  of  the  stomach  contents  ought  to  have  prevented  such 
errors. 

Finally,  cancer  must  be  distinguished  from  the  severe  forms  of 
hysteria.  At  the  first  glance  it  would  seem  almost  impossible  to 
mistake  these  two  conditions,  and  yet  there  undoubtedly  occur  cases 
in  which  an  extemporaneous  diagnosis  is  not  to  be  made,  and  even 
prolonged  observation  may  leave  us  in  doubt.  I  do  not  like  to  ac- 
knowledge the  possibility,  yet  it  has  happened  more  than  once  that 
hysterical  women  have  for  years  swallowed  portions  of  their  hair ; 
these  hairs  form  coils  in  the  stomach,  and  may  readily  simulate  a 
tumor  [see  page  376].  But,  even  without  these  "  complications," 
severe  forms  of  hysteria  may  lead  to  such  a  marked  disturbance  of 
nutrition  that,  especially  when  occurring  in  elderly  women,  the  sus- 
picion of  a  cancer  will  always  arise.  But,  as  a  rule,  you  will  dis- 
cover one  or  another  characteristic  symptom  which  will  enable 
you  to  make  a  positive  diagnosis.  The  following  case  may  serve 
as  an  example  : 

A  year  ago  I  was  consulted  by  a  Russian  lady,  flf  ty-two  years  old,  who 
had  had  four  children  ;  she  was  of  medium  stature,  and  stout.  Her  com- 
plaint was  that  for  some  time  she  had  been  unable  to  swallow ;  the  food 
could  not  pass  two  places  :  one  was  at  the  beginning  of  the  oesophagus, 
the  other  just  above  the  stomach.  When  this  occurred  she  had  severe 
pains,  which  ceased  suddenly  as  soon  as  she  felt  that  the  food  had  en- 
tered the  stomach.  The  pains  were  spasmodic.  At  the  same  time  there 
was  a  profuse  flow  of  saliva,  and  occasionally  she  also  complained  of 
shooting  pains  in  the  left  scapular  region.  She  had  taken  very  little 
fluid  nourishment  during  the  past  few  weeks,  and  claimed  to  have  run 
down  very  much. 

On  examination,  nothing  positive  could  be  discovered  except  that  the 
deglutition  murmurs  were  absent.  The  largest  oesophageal  bougies  could 
be  easily  passed  without  pain.  Repeated  passage  of  the  instruments  did  not 
bring  up  any  blood  or  pieces  of  tissue.  No  enlarged  glands  could  be  felt 
anywhere,  nor  could  any  tumor  be  palpated.  G-enital  organs  and  rectum 
were  found  normal.  There  was  absolutely  no  secretion  of  gastric  juice, 
and  neither  free  nor  combined  HCl  could  be  detected.  Although  the  age 
of  the  patient  and  the  whole  group  of  symptoms,  especially  the  pain  in 
the  shoulder,  caused  one  to  suspect  the  possibility  of  some  carcinomatous 
growth,  yet  it  seemed  by  no  means  improbable  that  the  case  might  be  one 
of  a  hysterical  spasm,  of  the  oesophagus.     Cases  giving  symptoms  similar 


366  DISEASES   OP   THE   STOMACH. 

to  these  have  been  described  by  Osgood,*  who  has  carefully  studied  this 
subject  and  collected  six  cases,  the  ages  of  which  varied  between  twenty 
to  fifty  years. 

The  subsequent  course  of  the  case  did  not  justify  these  views.  The 
patient  stayed  in  a  sanitarium  at  Berlin,  and  within  eight  to  ten  days  the 
administration  of  small  doses  of  morphine  and  condurango  caused  the 
cessation  of  the  difficulties  in  swallowing,  the  pains  and  salivation  ;  a 
thick  oesophageal  bougie  was  also  passed,  to  convince  her  of  the  iiermea- 
bility  of  the  oesophagus.  The  marked  anorexia  disappeared  more  slowly  ; 
yet  within  about  two  months  the  j)atient  was  able  to  leave  the  sanitarium 
with  a  good  appetite  and  only  occasional  gastric  j)ains.  She  never  even 
mentioned  the  dysphagia.  During  her  stay  in  the  sanitarium  she  was 
repeatedly  examined,  the  stomach  and  intestines  inflated,  but  never  was  a 
tumor  detected  by  myself  and  the  others  who  examined  her. 

The  diagnosis  thus  seemed  to  be  that  of  a  nervous  affection,  although, 
bearing  other  cases  in  mind,  I  was  quite  skeptical  about  it.  The  patient 
had  left  us  only  about  six  weeks,  when  we  received  a  letter  from  her 
family  physician  at  home  that  a  large  tumor  had  api^eared  in  the  hepatic 
and  epigastric  regions,  which  had  not  been  detected  by  the  physicians 
who  had  examined  her  a  fortnight  previously.  As  I  was  called  to  see  her 
at  her  home  to  determine  the  question  of  operative  interference,  I  had  the 
opportunity  of  convincing  myself  that  she  had  a  tumor,  the  size  of  which 
was  larger  than  a  fist,  and  which  involved  the  stomach  and  liver  and 
probably  also  the  omentum.  There  could  be  no  doubt  of  its  malignancy, 
for  a  short  time  afterward  the  patient  died. 

Treatment. — The  old  proverb  that  no  drug  is  potent  against  can- 
cer is  true  even  to-day,  however  depressing  such  an  admission  may 
be.  From  time  to  time  a  host  of  specifics  has  appeared,  from 
cicuta  and  belladonna  of  the  elder  Yogel,  Storck,  and  Hufeland, 
down  to  the  condurango  bark  of  Friedreich,  of  Heidelberg  ;  they  all 
owe  their  ephemeral  popularity  to  a  conscious  or  unconscious  decep- 
tion. At  best,  like  condurango,  they  only  relieve  symptoms  ;  they 
lessen  the  accompanying  catarrh  and  inci'ease  the  digestive  activity 
of  the  organ,  but  a  true  curative  action,  in  the  strict  sense  of  the 
word,  does  not  belong  to  them.  Although  no  one  now  considers 
condurango  as  anything  else  than  a  good  stomachic,  yet  the  follow- 
ing analysis  of  196  cases  of  gastric  cancer  by  Riess  f  is  nevertheless 
of  some  interest.  The  following  table  shows  the  result  upon  the 
mortality  and  the  duration  of  the  treatment : 

*  Osgood.  A  Peculiar  Form  of  CEsophagismus.  Boston  Medical  and  Surgical 
Journal,  April,  1889. 

f  L.  Riess.  Ueber  den  Werth  der  Condurangorinde  bei  dem  Symptombilde  des 
Magencarcinoms.     Bed.  klin.  Wochenschr.,  1887,  No.  10. 


TREATMENT  OF  GASTRIC   CANCER. 


367 


Cases  with  condu- 
rango  (80) 

Cases  without  con- 
durango  (116) ...  . 


Average 
duration  of 

treatment 
of  all  cases. 


43-4  days. 
21 -2  days. 


Deaths. 


53  (=66-3$^) 

107  (=92-2^) 


Average 
duration  of 
treatment. 


39-5  days. 
22-0  days. 


Discharged. 


27  (=38-7^) 
9(=    7-8;^) 


Average 
duration  of 
treatment. 


54*8  days. 
11-7  davs. 


It  is  to  be  noted  tliat  tlie  proportion  of  fatal  cases  with  and  with- 
out this  treatment  is  1 : 1-4  ;  a  similar  analysis  by  Immermann  gives 
the  proportion  of  1 : 1"3.  This  would  have  been  very  convincing 
had  the  diagnosis  of  gastric  cancer  been  positively  made  in  all  the 
cases,  and  had  the  discharged  patients  been  watched  for  a  long 
period. 

Some  may  object,  and  say  that  the  involution  of  palpable  tumors, 
which,  as  Riess  claims,  may  even  be  observed  with  a  tape  measure,  is 
a  very  significant  occurrence.  In  answer  to  this,  I  claim  that  the 
improvement  of  the  concomitant  catarrh  of  the  mucous  membrane 
may  lessen  the  hypergemia  and  the  size  of  the  tumor.  It  is  also  a 
well-known  fact,  to  which  I  have  directed  attention,  that  abdominal 
tumors  always  seem  larger  than  they  really  are  when  palpated 
through  the  abdominal  walls,  and  hence  increase  or  diminution  in 
size  will  be  manifested  on  a  larger  scale.  How  often  do  we  believe 
we  have  palpated  a  pyloric  tumor  about  the  size  of  a  walnut  or  a 
hen's  egg,  which  on  autopsy  proves  to  have  been  only  an  insignifi- 
cant muscular  hypertrophy  of  the  cervix  pylori !  * 

By  means  of  condurango  the  accompanying  gastric  catarrh  is 
improved,  and  the  same  beneficial  effects  are  obtained  in  genuine 
catarrhal  diseases  of  the  gastric  mucous  membrane;  hence  con- 
durango may  be  considered  an  excellent  stomachic  in  all  those  cases 
in  which  a  true  catarrhal  condition  of  the  gastric  mucosa  exists. 
Oser  has  expressed  similar  views.f  The  drug  is  best  administered 
according  to  the  following  formula;  it  is  to  be  noted  that  over- 


*  According  to  Retzius.  I  would  thus  designate  that  portion  of  the  pyloric  ring 
which  in  such  cases  projects  into  the  duodenum,  as  the  cervix  uteri  does  into  the 
vagina.  Bemerkungen  iiber  das  Antrum  pylori  beim  Menschen.  Muller's  Archiv, 
18o7. 

|-  Oser.  Ueber  den  Werth  der  Condurangorinde  in  der  Therapie  des  Magen- 
carcinoms.     Internat.  klin.  Rundschau,  1888. 


368  DISEASES  OF   THE  STOMACH. 

heating  will  destroy  the  glucosides  upon  which  the  activity  of  the 
preparation  depends : 

^   Cortic.  condurango 20-0-30-0  [  3  vj-  ^  j] 

Macer.  per  horas  xij  cum  Aq . .  300'0  [  §  x] 

Digere  lent,  calor.  ad  colatur. .  250*0  [  |  viij  3  ij] 

Adde 

Resorcin.  resublimat.  (or  tinct. 

nuc.  vomic.) 5*0  [  3  j^] 

Acid,  hydrochlor.  dil 3*0  [  3 1] 

Syr.  zingiberis  (or  syr.  f  oeniculi, 

menthse,*  etc.) ad  200*0  [  §  vj  3  vj] 

M.  Sig. :  One  tablespoonful  every  two  or  three  hours. 
Immermann  has  given  directions  for  making  a  condurango  wine. 
The  alcoholic  extraction  increases  the  cost  of  the  remedy  without, 
so  far  as  we  know,  extracting  any  special  ingredients  from  the  bark. 
For  this  reason,  when  it  is  indicated,  I  usually  order  the  watery  ex- 
tract, and  a  good  wine  to  be  taken  separately.  [In  the  United  States 
the  preparation  usually  employed  is  the  fluid  extract,  in  doses  of  a 
drachm  or  more.]  f 

Resorcin  is  added  to  the  above  mixture  to  obtain  its  antifermen- 
tative  effects ;  for  some  of  the  symptoms  from  which  these  patients 
suffer  are  not  due  to  the  neoplasm  per  se,  but  to  the  catarrhal 
changes,  stagnation  of  the  food,  fermentation,  etc.  Much  relief 
may  therefore  be  afforded  the  patients  by  attending  to  these  details. 
Hence  in  these  conditions,  as  well  as  in  vomiting,  lavage  may  at 
times  be  of  great  service  even  though  there  is  no  actual  dilatation 
of  the  stomach. 

Vomiting  ceases  or  is  lessened  by  swallowing  small  pieces  of  ice 


*  [Syrup  of  fennel  and  of  peppermint  (Phar.  German.)  are  both  10-per-cent  solu- 
tions.— Ed] 

t  [Sufficient  time  has  not  yet  elapsed  to  pass  a  correct  judgment  on  the  value 
of  methylene  blue,  which  was  proposed  as  a  specific  against  inoperable  malignant 
neoplasms  by  Prof.  Von  Mosetig-Moorhof  (Wiener  klin.  Wochenschr.,  1891,  No.  6, 
p.  101 ;  ibid..  No.  12,  p.  34).  The  general  tendency,  however,  is  unfavorable  toward 
the  claims  of  its  specific  action.  For  bibliography,  see  W.  Meyer.  Notes  on  the 
Effects  of  Aniline  Dyes,  etc.  New  York  Med.  Record,  vol.  xxxix,  pp.  473-478.  In 
some  cases  analgesic  effects  are  also  obtained  with  it.  Still,  this  does  not  warrant 
the  great  annoyances  to  which  its  use  for  a  prolonged  period  subjects  the  patient. 
—Ed.] 


TREATMENT  OF  GASTRIC  CANCER.  369 

with  a  few  drops  of  cliloroform,  ice-cold  carbonic  water  in  teaspoon- 
f ul  doses,  effervescing  lemonade  or  champagne  (one  of  my  patients 
insisted  on  having  "  Weiss  Bier  "  for  his  vomiting,  and  bore  it  well), 
and  morphine  internally  or  hypodermically.  Occasionally,  tem- 
porary relief  may  be  obtained  by  the  use  of  suppositories  with  10  to 
25  milligrammes  [gr.  i  to  -j^]  of  opium. 

The  action  of  ferric  chloride,  which  was  formerly  so  highly 
lauded  in  hoematemesis,  is  very  doubtful ;  it  is  also  hard  to  under- 
stand how  it  can  act  when  given  in  the  dilution  necessary  to  prevent 
corrosion.  ]S"ature  has  provided  for  the  stoppage  of  haemorrhage 
from  the  smaller  vessels  by  means  of  thrombosis;  the  bleeding 
from  larger  vessels  can  not  be  influenced  by  ferric  chloride.  Much 
better  results  are  obtained  by  cold  (swallowing  cracked  ice,  and  cold 
compresses  to  the  abdomen)  and  ergot.  I  order  a  doubly  purified 
extract  of  secale  cornutum  (Pharra.  Germ.)  in  a  50-per-cent  solu- 
tion of  glycerin  and  water ;  of  this  I  inject  two  to  three  Pravaz 
syringefuls  ^  in  the  epigastrium  in  the  course  of  half  an  hour  ;  we 
may  also  give  10  to  20  drops  of  this  solution  internally  every  hour.f 
We  may  use  ergot  freely,  since  it  has  been  calculated  that  the  poison- 
ous effects  of  sclerotinic  acid  do  not  appear  in  human  beings  till  about 
10  grammes  [  3  ijss.]  have  been  taken.  Our  knowledge  of  sclerotinic 
acid  being  still  vague,  it  is  better  to  use  the  extract  of  ergot.  How- 
ever, the  effectiveness  of  the  remedy  must  not  be  judged  by  the  pos- 
sible results  in  controlling  the  bleeding  in  cases  of  cancer,  where  the 
walls  of  the  blood-vessels  are  degenerated  and  adherent  to  a  more 
or  less  rigid  tumor.  Its  action  is  much  more  pronounced  in  gastric 
ulcer  {q.  v.). 

As  mild  analgesics  we  may  try  rubbing  in  chloroform  hniment 
hydropathic  applications  with  camomile  infusion,  warm  poultices, 
affusions  to  the  abdomen,  etc.    I  have  obtained  no  good  results  from 


*  [The  capacity  of  the  Pravaz  hypodermic  syringe  is  one  gramme  (15  minims). 
—Ed.] 

f  [For  hypodermic  use,  good  fluid  extracts  of  ergot  orergotole,  diluted  with  one 
or  two  parts  of  water,  answer  every  purpose.  Sometimes  the  sohition  is  not  clear  ^ 
if  this  is  the  case,  it  is  unfit  for  use.  The  injections  should  be  carefully  made  ;  yet 
sometimes,  in  spite  of  all  care,  painful  spots,  or  even  small  abscesses,  are  left.  Cold 
applications  of  witch-hazel  are  very  soothing  if  pain  is  present  at  the  site  of  the 
injection. — Ed.] 


370  DISEASES  OP   THE   STOMACH. 

cocaine  in  tMs  disease  ;  chloral  lias  been  more  useful,  yet  at  times 
the  hypnotic  effect  predominated  too  much  over  its  sedative  action. 
The  preparations  of  opium  labor  under  the  great  disadvantage  that 
they  paralyze  still  further  the  already  retarded  intestinal  peristalsis. 
This  is  especially  true  of  opium,  since  it  is  well  known  that  mor- 
phine or  codeine  aifects  the  intestines  much  less.  Yet  even  here 
we  encounter  idiosyncrasies,  so  that  the  use  for  a  few  days  of  very 
small  doses  of  morphine,  only  5  to  10  milligrammes  [gr,  Jg  to  |-], 
may  cause  obstinate  constipation.  Belladonna  has  for  a  long  time 
enjoyed  the  reputation  of  being  antagonistic  to  this  action  of  opium, 
but  as  a  rule  it  has  been  given  in  too  small  doses.  We  may  add 
20  to  50  milligrammes  [gr.  i  to  f  ]  of  extract  of  belladonna  to  10 
milligrammes  [gr.  i]  of  morphine ;  for  hypodermic  use  add  -jifj-  part 
of  sulphate  of  atropine.  But  all  persons  do  not  react  alike  to  bella- 
donna ;  hence,  dilatation  of  the  pupils,  dryness  of  the  tongue,  and 
irritation  in  the  throat  may  occur  very  early,  and  after  very  small 
doses.  It  is  therefore  advisable  to  warn  patients  of  the  possible 
effects  of  the  drug.  A  patient  with  cancer  of  the  large  intestines 
and  metastases  in  the  liver  and  retroperitoneal  glands  once  refused 
to  take  some  pills  because  he  read  extract  of  belladonna  on  the 
prescription.  He  asserted  that  he  was  at  once  affected  with  a  most 
annoying  dryness  in  the  throat  and  difficulty  in  swallowing.  I 
thought  that  this  was  at  least  highly  exaggerated,  and  ordered  ex- 
tract of  belladonna,  O'l  gramme  [gr.  jss.],  to  be  given  without  his 
knowledge  in  a  suppository.  The  next  day  he  complained  that  the 
suppository  had  produced  the  typical  effects  of  belladonna,  and  he 
reproached  me  for  having  imposed  on  him. 

The  constipation  should  be  relieved  as  long  as  possible  by  mild 
vegetable  aperients.  The  various  salines  are  to  be  avoided,  since 
they  needlessly  weaken  the  patient  by  the  loss  of  fluid,  and  may 
easily  cause  diarrhosa.  Where  the  constipation  is  marked,  we  may 
use  cathartic  pills,  like  those  mentioned  under  dilatation  of  the 
stomach  (page  302).  Where  fseces  have  accumulated  in  the  large 
intestines  enemata  are  indicated,  either  of  lukewarm  water  alone, 
or  with  laxative  agents  like  glycerin  injections,  which  may  be  given 
up  to  30  to  50  grammes  [  5  j  to  %]Z'y\  and  glycerin  suppositories ; 
yet  all  these  fail  as  soon  as  there  is  a  general  paresis  of  the  gut  and 


TREATMENT  OP  GASTRIC  CANCER.  371 

an  accnmiilation  of  tlie  fseces  in  the  small  intestines.  For  diarrhoea 
we  may  use  oiDium  in  suppositories  or  in  enemata.  There  is  no  in- 
dication for  loading  the  stomach  with  the  familiar  astringents — 
calumba,  hsematoxylon,  catechu,  nitrate  of  silver,  tannin,  etc. — 
because  the  diarrhoeal  passages  are  due  to  such  extensive  anatomical 
lesions  that  the  mild  astringents  and  the  anticatarrhal  remedies  are 
absolutely  useless. 

In  the  chapter  on  Dilatation  of  the  Stomach  I  have  already  dis- 
cussed the  treatment  of  accumulation  and  decomposition  of  the  stom- 
ach contents  which  follow  the  stenosing  of  the  pylorus  by  a  tumor. 

A  diet  of  starches  and  vegetables  is  more  easily  borne  than  one 
of  meat,  since  the  diminution  in  the  secretion  of  hydrochloric  acid 
causes  the  digestion  of  albumen  and  meat  to  be  incomplete.  In 
most  cases  milk  is  also  poorly  borne  on  account  of  the  absence  of 
rennet,  and  not  even  the  addition  of  soda  or  lime  water,  which 
normally  stimulate  its  secretion,  will  be  of  any  service.  It  would 
be  better  to  add  a  few  drops  of  cognac  to  a  tablespoonful  of  milk* 
Koumiss,  matzoon,  and  peptonized  milk  are  relished.  The  other 
artificial  food  products  are  also  indicated,  especially  the  meat  pep- 
tones in  bouillon,  soups,  sauces,  etc. ;  it  is  greatly  to  be  regretted 
that  the  patients  tire  so  soon  of  even  the  best  of  them  (Kemmerich's 
or  Koch's  meat  peptones,  Leube's  beef  solution,  and  Denayer's  and 
Antweiler's  albumose  peptones).  Meat-peptone  chocolate  is  rel- 
ished. [Somatose  has  been  highly  commended  as  a  food  in  these 
cases.]  Kecently  peptone  beer — i.  e.,  heavy  beer  to  which  albumose 
peptone  has  been  added — has  been  introduced ;  the  taste  is  fairly 
pleasant  and  the  nutritive  value  quite  high.* 

The  otherwise  very  commendable  soups  of  leguminous  flour, 
l^estle's  food,  and  the  like,  labor  under  the  same  disadvantage.  All 
kinds  of  food  should  be  cut  up  as  fine  as  possible,  or  should  be  eaten 
in  the  form  of  paps. 

For  many  patients  such  a  diet  of  paps  and  finely  divided  fpod  is 
a  veritable  torture.  The  muscles  of  mastication  and  the  salivary 
glands  feel  an  almost  irresistible  desire  to  be  once  more  in  action, 
and  the  palate  longs  for  a  hearty  and  delicious  morsel.     When  this 

*  Ewald  und  Grumlich.  StofEwechselversuche  mit  Kraftbier.  Berl,  klin.  Wo- 
chenschr.,  1890. 


372  DISEASES  OF   THE  STOMACH. 

condition  is  readied — usually  it  is  about  the  middle  of  tlie  course  of' 
the  disease — it  is  pardonable  if  the  rules  are  somewhat  relaxed  and 
the  patient  allowed  to  satisfy  his  longings,  unless,  of  course,  such  an 
allowance  is  positively  injurious.  This  course  is  the  more  justifi- 
able as  the  end  of  the  disease  is  marked  by  complete  anorexia. 
After  all,  we  usually  deal  with  people  whose  main  desire  has  been  a 
well -supplied  table,  and  such  a  relaxation  affords  them  the  last  pleas- 
ure of  their  lives. 

There  is  at  least  one  group  of  foods  which  must  always  be 
avoided,  namely,  those  inclosed  in  tough  envelopes,  which  not  even 
cooking  will  soften,  or  which  are  permeated  by  bundles  of  dense 
connective  tissue,  enabling  them  to  resist  the  action  of  the  digestive 
juices  for  a  long  time.  To  this  group  must  also  be  added  the  fer- 
mented liquors  containing  a  large  percentage  of  fermentable  sub- 
stances, and  also  the  fats  whose  prolonged  stay  in  the  stomach  causes 
them  to  decompose  and  thus  cause  trouble. 

From  the  theoretical  standpoint  of  their  high  caloric  value.  Yon 
l^oorden  *  has  quite  properly  recommended  generous  supplies  of 
fats  in  the  dietary  of  patients  with  gastric  disorders ;  he  believes 
that  good  pure  fat  is  better  borne  than  is  usually  supposed.  The 
actual  results  of  a  very  large  practical  experience  have  shown  that 
the  greatest  differences  exist  in  different  patients  in  this  regard,  and 
that  one  can  not  tell  a  priori  how  fat  will  be  borne  by  patients. 
Everything  depends  on  the  reciprocal  action  of  the  stomach  and 
intestines,  how  long  the  food  remains  in  the  stomach,  and  upon  the 
individual  idiosyncrasy  of  the  patient.  For  a  long  time,  taking  the 
same  ground  as  Yon  Koorden,  I  have  been  in  the  habit  of  recom- 
mending fats ;  but  unfortunately  they  are  usually  poorly  borne,  just 
like  eggs,  the  amount  of  fat  of  which  is  also  high  (12  per  cent). 

There  are  other  foods  which  may  be  allowed,  but  which  are  very 
differently  borne  by  individual  patients.  Here  the  personal  experi- 
ence of  the  patient  is  the  best  guide.  Furthermore,  the  anxious 
sufferer  may  be  placed  in  a  dilemma  by  one  physician  allowing 
what  another  has  forbidden.  If  we  do  not  know  what  has  already 
been  recommended,  it  is  well  not  to  give  a  definite  bill  of  fare,  but 

*  Von  Noorden.    Ueber  den  Stoff wechsel  des  Magenkranken  und  seine  Anspriiche 
an  die  Therapie.    Berliner  Klinik,  January,  1893,  Heft  55. 


TREATMENT  OP  GASTRIC  CANCER.  373 

to  follow  Trousseau's  advice,  to  refer  the  patient  to  his  own  experi- 
ence. 

All  of  the  above  refers  only  to  the  first  stage  of  the  disease, 
when  the  so-called  dyspeptic  symptoms  constitute  the  chief  part  of 
the  clinical  picture.  Later,  the  choice  of  food  becomes  more  and 
more  restricted,  till  finally  it  is  limited  to  thin  broths  (flour,  rice, 
sago,  and  tapioca),  with  the  addition  of  peptones,  finely  scraped 
white  meat,  jellies  of  rice  and  calves'  feet,  eggs  (if  they  can  be  di- 
gested), bouillon,  and  the  hke.  Bouillon  is  usually  rejected  very  soon. 
The  patient's  strength  is  to  be  maintained  by  stimulating  beverages 
like  strong  teas,  good  clarets,  the  so-called  dessert  wines  (except  port, 
which  is  too  highly  sweetened),  and  finally  champagne.* 

Treatment  at  the  mineral  springs^  or  the  home  consumption  of 
these  waters,  is  naturally  useless  after  the  diagnosis  has  once  been 
positively  made.  But  the  disease  is  easily  and  frequently  mistaken 
in  its  early  stages,  and  the  patient  on  his  own  or  his  physician's  ad- 
vice goes  to  one  of  the  celebrated  spas  like  Carlsbad,  Marienbad, 
Ems,  Yichy,  etc.,  to  cure  his  "  chronic  stomach  catarrh."  Then 
later  on  we  hear  the  familiar  reproach  against  the  doctor  '*  who  sent 
me  to  the  wrong  spring."  This  condition  of  things  will  be  im- 
proved in  the  future  when  the  chemical  diagnostic  aids  will  be  more 
generally  employed,  and  thus  enable  us  to  have  at  least  a  suspicion 
early  in  tlie  disease  and  to  act  accordingly.  Many  patients,  without 
knowing  \vhat  their  true  condition  is,  insist  on  going  to  some  spring. 
"  I  then  permit  them  to  carefully  take  small  quantities  of  the  cor- 
responding water  at  home,"  says  Lebert,  "  and  as  they  usually  de- 
rive no  benefit  from  it,  they  soon  renounce  the  trip  to  the  spring 
itself." 

[Surgical  Treatment.— Theoretically  speaking,  the  treatment  of 
carcinoma  of  the  stomach  ought  to  be  regarded  just  as  cancer  is 
considered  in  other  parts  of  the  body — i.  e.,  excision  as  soon  as  a 
positive  diagnosis  has  been  made.  The  reduction  in  the  mortality 
and  the  improvement  in  the  diagnostic  methods  which  enable  us  to 
recognize  this  condition  at  a  much  earlier  period  than  formerly  are 
encouraging  features.     To  wait  for  a  palpable  tumor  and  cachexia 

*  [For  further  details  on  diet,  see  Thompson's  Dietetics,  pp.  525-529. — Ed.] 


374 


DISEASES  OP  THE  STOMACH. 


is  often  fatal  to  tlie  patient's  chances.     And  yet,  even  if  a  tumor 
is  present,  we  must  bear  in  mind  that  tumors  always  feel  larger 
than  thej  really  are.     If  the  patient's  general  condition  is  good 
and  metastases  have  not  yet  formed,  if  extensive  adhesions  to  the 
adjacent  viscera  (liver  and  pancreas)  have  not  been  contracted,  if 
the  glands  and  omentum  are  free,  we  may  safely  advise  operative 
procedure.     The  possibilities  of  operative  measures  are  well  shown 
by  Kocher's,  Wolffler's,  and  Hahn's  cases,  which  were  still  alive 
and  comfortable  5^,  5,  and  3  years  after  operation,  and  by  Eosen- 
heim's  *  report  of  twenty  cases  which  were  treated  surgically ;  in  8 
the  pylorus  was  resected,  m  12  gastroenterostomy  was  performed. 
Three  of  the  resection  cases  died  soon  after  the  operation  ;  of  the 
other  5,  three  are  alive  and  doing  well  (one  2  years,  the  other  4  years 
after  the  operation) ;  the  fourth  was  comfortable  for  a  year,  and 
then  died  of  malignant  peritonitis ;  the  fifth,  also  died  of  the  latter. 
Of  the  twelve  cases  which  were  operated  by  gastroenterostomy 
none  died  of  the  operation.     All  recovered  rapidly,  were  more  or 
less  free  from  symptoms,  and  gained  in  weight.     Three  died  at  the 
end  of  1  to  4  months.     The  others  lived  from  9  months  to  2  years. 
Rosenheim  adds  that  in  all  of  these  cases  the  disease  was  well  ad- 
vanced, and  hence  even  better  results  may  be  expected  if  the  oper- 
ations are  performed  earlier.     Furthermore,  we  must  expect  that 
the  improvement  in  the  technique  also  means  a  lower  mortality  rate. 
Thus  Hahn  f  did  15  successive  gastroenterostomies  without  a  death, 
70  per  cent  of  the  cases  being  cancers.     The  improvement  in  the 
mortality  rates  after  pylorectomy  is  well  shown  in  a  table  given 
by  Kronlein  : ;]: 


Year. 

Operator. 

No.  of 
cases. 

Recov- 
ered. 

Died. 

Mortality 
per  cent. 

1890 

Billroth 

29 
16 
13 
18 
15 

13 

9 

8 

13 

11 

16 
7 
5 
5 
4 

55-1 

1895 

Czerny  

43-7 

1894 

Kappeler 

38-4 

1895 

Mikulicz 

27-7 

1895 

Kronlein 

26-6 

Total 

91 

54 

37 

40-6 

average. 

*  [Rosenheim.     Deutsch.  med.  Wochenschr.,  1895,  Nos.  1-3. — Ed.] 
t  [Hahn.     Deutsch.  med.  Wochenschr.,  1894,  No.  43.— Ed.] 
X  [Kronlein.    Bruns's  Beitrage,  Bd.  sv,  p.  315. — Ed.J 


NON-CANCEROUS  TUMORS  OF  STOMACH.  375 

The  latest  statistics  of-  gastroenterostomy  are  those  of  Hahn's 
above  quoted,  and  Eockwitz,  12^  per  cent.  The  respective  indica- 
tions, according  to  the  present  views,  are  that,  taken  all  in  all, 
gastroenterostomy  offers  the  best  chances  for  pyloric  cancers. 
Cancers  of  the  cardia  are  inoperable  except  by  gastrostomy  for  feed- 
ing purposes.  If  the  diagnosis  has  been  made  early,  and  there  are 
no  extensive  adhesions,  resection  of  the  pylorus  may  be  performed. 
In  complicated  or  advanced  gastroenterostomy,  if  in  doubt,  an  ex- 
ploratory laparotomy,  with  consent  to  do  what  is  best,  is  the  proper 
course.]  * 

[The  Non-Cancerous  Tumors  of  the  Stomach. — Concerning  these 
Kttle  need  be  said,  for  "  they  are  comparatively  rare  and  are  usually 
unattended  by  [special]  symptoms.  Even  should  a  tumor  be  dis- 
covered, there  are  no  means  of  determining  the  nature  of  the 
tumor  ;  and  if  symptoms  are  produced  by  the  tumor,  the  case  will 
probably  be  diagnosticated  as  one  of  cancer."  f 

These  tumors  may  be  benign  or  malignant — primary  or  second- 
ary. They  include  papillomata,  fibromata,  lipomata,  myomata, 
lymphomata,  adenomata,  sarcomata,  myosarcomata,  and  lympho- 
sarcomata. 

The  most  important  of  these  non- cancerous  gastric  tumors  are 
the  sarcomata.  They  are  rarely  found,  as  may  be  inferred  from  the 
fact  that  Kriiger  %  was  able  to  collect  only  19  cases,  and  Eosch  * 
only  11.  The  small  round-celled  type  is  the  most  common.  There 
is  little  tendency  to  ulcerate.  Metastases  are  infrequent.  A  case 
of  fibrosarcoma  is  reported  on  page  362. 

Fibromata  and  myofibromala  are  also  rare  and  are  usually 
found  at  autopsies,  as  they  are  so  small  that  they  give  rise  to  few  or 
no  symptoms,  unless  they  assume  a  polypoid  form.  Tilger  \  found 
them  in  10  out  of  3,000  stomachs. 

*  [See  also  the  surgical  treatment  of  dilatation  of  the  stomach,  pages  306  to  309. 
—Ed.] 

f  [Welch.  Loo.  cit.,  p.  578.  In  addition  to  eases  reported  there,  see  P.  Albertoni. 
Rivista  clinica  e  terapeutica.  Naples,  November  12,  1889.— Kunze,  Arch,  fiir  klin. 
Chirurgie,  Bd.  xl.  Heft  3.— Malvoz.  Annales  de  la  Societ.  med.  chir.  Liege,  August 
and  September,  1889.— Ed.] 

X  [P.  Kriiger.     Quoted  by  Rosenheim,  op.  cit.,  p.  393. — Ed.] 

*  [Rosch.     Quoted  in  Boas's  Arch.,  Bd.  i,  p.  113.— Ed.] 
II  [Tilger.     Virchow's  Arch.,  Bd.  cxsxiii. — Ed.] 

25 


3Y6  DISEASES  OP  THE  STOMACH. 

Lymphadeno'mata  have  already  been  discussed  on  page  323. 

Cysts,  including  traumatic  cysts,  are  also  occasionally  encoun- 
tered. A  case  of  the  latter  has  been  decided  by  Ziegler.*  Foreign 
bodies,  especially  balls  of  hair  and  gastroliths,  may  simulate  tumors. 
These  foreign  bodies,  which  may  simulate  mahgnant  tumors,  are 
usually  spherical  or  ovoid  agglomerations  of  hairs  f  which  have  been 
swallowed.  But  similar  errors  may  arise  from  "  shellac  calculus  " 
{Shellackstein\X  as  occurred  in  a  carpenter  who  mistook  his  varnish 
for  liquor  ;  other  foreign  bodies  of  a  similar  nature  have  given  rise 
to  errors.  Gastric  calculi,  or  gastrohths,  sometimes  reach  a  very 
large  size.     A  unique  case  of  this  kind  was  reported  by  Kooyker  : 

The  patient  was  a  druggist,  thirty-five  years  old,  who  had  a  circum- 
scribed tumor  in  the  epigastrium,  the  position  of  which  varied  on  respira- 
tion, and  which  was  tender  on  pressure.  Medicines  had  no  permanent 
eilect.  Spleen,  liver,  and  kidneys  normal.  Appetite  good  ;  bowels  regu- 
lar. Occasional  vomiting  of  a  small  quantity  of  fluid  containing  mucus 
and  bile,  but  never  free  hydrochloric  acid.  Nausea  was  constant,  and  it 
was  said  haematemesis  occurred,  but  this  was  not  actually  observed. 
Gradual  emaciation  followed,  with  cachexia  and  indolent  swelling  of  the 
left  supraclavicular  and  axillary  glands.  The  patient  was  examined 
under  an  ansesthetic  and  the  stomach  washed  out,  but  exploratory  inci- 
sion was  steadily  refused.  The  diagnosis,  according  to  the  probabilities, 
was  cancer  of  the  stomach.  The  case  ended  fatally  ;  the  autopsy  showed 
that  the  stomach  was  normal  in  size,  but  contained  a  large  concretion, 
weighing  885  grammes  (over  28  ounces),  and  having  the  outlines  of  the 
organ.  At  the  pyloric  end  there  were  two  smaller  fragments  the  size  of 
hen's  eggs.  The  gastrolith  had  a  strong  fecal  odor,  but  contained  no 
skatol.  No  nucleus  was  present.  Microscopic  examination  showed  starch 
granules,  cells  containing  chloropliyl,  bundles  of  vessels,  but  nothing  to 
determine  the  animal  origin  of  the  concretion.  It  'vias  identical  in  com- 
position with  the  "food-balls"  of  ruminants.] 

*  [Ziegler.     Miinch.  med.  Woehenschr.,  No.  6,  1894.— Ed.] 

f  Palemon  Best,  Death  from  Accumulation  of  Hair  in  the  Stomach  of  a 
Woman,  British  Medical  Journal,  December  11,  1869,  and  other  English  authors. 
The  eating  of  hair  seems  to  be  a  favorite  occupation  of  English  women ;  still,  un- 
less I  am  mistaken,  a  similar  case  was  reported  by  Schonborn. — Bufsel.  A  Case  in 
which  the  Cavity  of  the  Stomach  was  Occupied  by  an  Enormous  Mass  of  Human 
Hair.     Medical  Times  and  Gazette,  June  26,  1869. 

[Another  German  case  may  be  found  in  0.  Bollinger.  Eine  seltene  Haarge- 
schwi;lst  im  menschlichen  Magen.  Miinchen.  med.  Woehenschr.,  1891,  Bd.  sxxviii, 
S.  383.  The  case  of  Schonborn,  alluded  to  above,  may  be  found  in  Arch,  fiir  klin. 
Chirurg.,  Bd.  sxix,  S.  609;  the  ball  of  hair,  which  was  mistaken  for  a  movable  kid- 
ney, was  successfully  removed  by  ojaeration. — Ed.] 

X  [Zeitschrift  fiir  klin.  Med.,  Bd.  xiv,  Heft  3. — An  additional  case  of  gastric  shel- 
lac calculus  of  large  size  has  recently  been  reported  by  Menasse,  Berl.  klin.  Woeh- 
enschr., 1895,  No.  83.— Ed.] 


CHAPTEK  YIII. 

ULCER   OF   THE    STOMACH ULCUS   PEPTICUM    SEU   EODENS. 

I  SHALL  preface  the  discussion  of  this  disease  by  relating  the 
following — in  many  respects — remarkable  case  : 

The  patient,  aged  thirty-five,  was  a  married  man,  father  of  two  healthy 
children,  an  architect  by  profession,  whose  work  had  of  late  fallen  off, 
and  who  was  subjected  to  much  excitement  and  worry.  From  his  youth 
he  had  shown  a  tendency  to  embonpoint  \  he  was  a  hearty  eater,  and  a 
still  heartier  drinker  of  Bavarian  beer.  He  never  had  syphilis,  and  had 
always  been  in  good  health.  For  the  past  year  he  had  now  and  then 
complained  of  pain  in  the  abdomen,  as  a  rule  not  localized,  and  only  occa- 
sionally referred  to  the  right  side.  At  times  he  was  somewhat  irritable, 
and  suffered  from  insomnia.  In  spite  of  good  care  he  lost  flesh  constantly 
— about  88  pounds  during  the  past  year ;  his  weight  was  reduced  from  204 
to  116  pounds.  This  was  so  conspicuous  as  to  cause  him  anxiety.  His 
occasional  attacks  of  abdominal  pain  were  ascribed  by  his  relatives  to  all 
manner  of  secret  dietetic  errors. 

On  examination  with  my  colleague.  Dr.  Gr..  no  abnormalities  either  in 
the  nervous  system  or  in  the  systemic  organs  could  objectively  be  discov- 
ered, with  the  exception  of  slight  pain  on  deep  pressure  in  the  praecordium, 
such  as  is  present  in  all  cases  of  gastric  catarrh.  Appetite  good,  tongue 
clean,  bowels  irregular,  but  easily  regulated  by  a  mild  cathartic.  There 
was  frequent  flatulence.  His  general  condition  was  feeble ;  he  was  lan- 
guid, and  had  lost  all  interest  in  his  work.     The  urine  was  normal. 

In  view  of  the  great  loss  of  weight,  we  could  not  be  satisfied  with  the 
idea  that  this  was  a  case  of  simple  catarrh  of  the  digestive  tract,  which 
was  the  opinion  of  others,  and  we  consequently  concluded  to  observe  the 
patient  while  under  a  strict  diet.  •  For  this  purpose  he  was  admitted  to  the 
sanitarium,  and  placed  upon  a  nourishing  but  somewhat  restricted  diet. 
During  the  first  few  days  infusion  of  rhubarb  was  given,  with  a  prompt 
result.  Examination  of  the  expressed  stomach  contents,  after  a  test  break- 
fast, revealed  a  normal  quantity  of  hydrochloric  acid,  peptone,  and  achro- 
odextrin — no  granulose.  On  the  whole  he  felt  well,  complaining  only  of 
transient  lack  of  sleep  and  pain  in  the  limbs,  ascribed  to  the  unaccus- 
tomed confinement  to  his  room  and  to  the  fact  that  he  was  only  permitted 
to  be  up  two  hours  daily.  In  spite  of  this  the  loss  of  weight  continued, 
amounting  to  half  a  pound  during  the  first  week  and  three  quarters  of  a 
pound  during  the  second.  On  the  sixteenth  day  he  insisted  on  goii'g  out 
to  attend  to  some  business  matter.     This  he  did  during  the  morning  m 

377 


378  DISEASES  OP   THE  STOMACH. 

company  with  his  wife,  and  while  gone  he  positively  committed  no  error 
in  diet.  In  the  course  of  the  afternoon  he  suddenly  became  very  restless, 
rang  the  bell  repeatedly,  and  always  a  number  of  times  in  succession,  for 
the  servant  to  get  him  this  or  that  trifle.  Suddenly,  without  any  nausea, 
he  vomited  about  one  litre  [quart]  of  fresh,  bright-red  blood  mixed  with  a 
little  mucus.  The  indicated  medication  (ergot,  morphine,  cold  local  ap- 
plications, and  swallowing  small  pieces  of  ice)  was  at  once  exhibited,  and 
he  passed  the  night  without  any  further  attack.  The  next  morning  he 
had  two  fresh  haemorrhages,  preceded  by  excitement,  and  in  the  course  of 
the  day  seven  bloody  stools — at  first  dark-brown,  fairly  hard  masses,  then 
tarry  evacuations,  and  finally  nearly  pure  blood.  He  became  intensely 
anaemic,  so  that  the  question  of  transfusion  was  considered,  but  the  pulse 
rallied,  and  the  patient  passed  a  good  night.  On  the  following  day  he 
was  in  a  comparatively  good  condition,  so  that  he  could  see  his  wife  and 
father.  Nevertheless,  I  was  called  to  see  him  the  next  night,  because  he 
had  suddenly  fallen  into  a  comatose  condition.  He  is  said  to  have  con- 
versed at  eleven  o'clock,  and  to  have  assured  the  house  physician  that  he 
felt  well.  At  two  o'clock  I  found  the  patient  fully  unconscious,  with 
faint  conjunctival  reflex,  small,  wiry  pulse,  retracted  abdomen,  cold  skin, 
and  well-marked  Cheyne-Stokes  respiration.  He  had  several  bloody  stools, 
and  died  at  5  A.  M. 

He  received  in  all  2  grammes  [gr.  xxx]  of  the  extract  of  ergot  subcu- 
taneously,  and  about  50  milligrammes  [gr.  |]  of  morphine  and  opium, 
partly  hypodermically  and  partly  in  suppositories.  Considering  all  that 
had  taken  place,  no  doubt  could  exist  that  the  diagnosis  was  ulcer,  with 
haemorrhage.  Its  site,  however,  whether  it  was  in  the  stomach  or  in  the 
duodenum,  remained  questionable,  as  also  the  cause  of  the  final  catas- 
trophe. Had  there  been  a  perforation,  or  did  a  complication  arise  in  the 
form  of  cerebral  apoplexy  ?  The  soporific  condition  and  the  type  of  respi- 
ration most  frequently,  if  not  exclusively,  seen  in  injuries  of  the  brain 
seemed  to  point  to  the  latter,  while,  opposed  to  the  former,  was  the  absence 
of  air  in  the  abdomen,  as  well  as  the  manifestly  slight  sensitiveness  of  the 
abdominal  walls. 

The  autopsy  gave  the  following  results  [Fig.  45] : 

Abdominal  walls  moderately  tense  and  vaulted.  On  opening  the  ab- 
dominal cavity  some  air  escaped.  In  the  abdomen  was.  a  considerable 
quantity  of  fresh  blood.  The  coils  of  intestine  were  somewhat  flabby,  the 
serosa  moderately  injected.  In  the  center  of  the  anterior  wall  of  the 
stomach  was  found  a  rectangular  perforation  about  the  size  of  a  bean, 
with  blackish,  bloody  margins.  The  serous  coat  of  the  stomach  was  dot- 
ted with  numerous  small  greenish  points.  There  were  five  losses  of  sub- 
stance in  the  stomach,  varying  in  size  and  depth  ;  the  largest  was  situated 
midway  between  the  pyloric  and  cardiac  ends,  the  others  in  the  lower 
third  of  the  stomach.  The  large  ulcer  was  almost  rectangular  in  shape, 
4"2  centimetres  [1^^^  inch]  in  length  by  2  centimetres  [f  inch]  in  width.  It 
extended  to  the  serous  coat,  and  toward  the  pylorus  showed  the  above- 
mentioned  perforation,  which  was  divided  in  half  by  a  thin,  threadlike 
bridge  of  serous  membrane.  In  the  center  of  the  base  of  the  ulcer  the 
serous  coat  was  somewhat  thicker,  becoming  thin  again,  and  also  trans- 
parent like  tissue  paper,  toward  the  cardiac  end.     At  this  situation  there 


ULCER  OF   STOMACH. 


379 


/ 


/ 


'  K 


^^^r->^,-. 


p- 


Fig.  45.-Perforating  ulcer  of  stoiuacli.     c,  cardia ;  p,  pylorus  ;  u,  perforating  ulcer. 


380  DISEASES  OF   THE  STOMACH. 

was  a  thrombosed  and  very  tortuous  vessel,  about  the  diameter  of  a  pin, 
from  which  the  fatal  haemorrhage  arose.  The  margins  of  the  ulcer  in  the 
lower  and  middle  portions  were  thickened,  wall-like,  and  undermined ; 
in  the  upper  portion  they  ran  gradually  into  the  intact  mucous  mem- 
brane. 

The  other  ulcers  extended  only  to  the  muscular  layer,  or  were  limited 
to  the  mucous  membrane.  In  one  of  these  the  remains  of  a  small  throm- 
bosed vessel  could  be  observed.  The  rest  of  the  mucous  membrane  was 
in  the  usual  condition,  except  that  the  small  greenish  points  described 
above  as  appearing  on  the  serous  coat  were  also  seen  here.  The  micro- 
scope revealed  a  catarrhal  condition  in  the  fundus  and  pylorus,  with 
marked  cellular  infiltration  and  cloudy  glandular  cells.  The  "green 
points  "  were  not  due  to  extravasations  of  blood,  but  were  produced  by 
the  vessels  of  the  submucosa,  which  were  uncommonly  enlarged  and  mark- 
edly tortuous,  and  especially  by  the  veins,  which  were  widely  distended 
with  blood.  There  was  no  amyloid  degeneration.  In  the  intestines  were 
found  large  quantities  of  thin  fluid  blood.  The  remaining  abdominal 
viscera  were  normal,  but  anaemic  to  a  high  degree. 

This  case  presents  several  deviations  from  the  common  type  of 
gastric  nicer,  not  only  in  regard  to  the  course  of  the  disease,  or 
rather  its  latency,  bnt  also  on  account  of  the  not  very  common  form 
of  the  ulcer  and  the  perforation,  and  finally  in  the  uncommon  mani- 
festations to  which  the  perforation  itself  gave  rise.  I  will  return  to 
this  later  on. 

I  shall  now  describe  the  clinical  picture  of  the  so-called  round, 
but  better  named  chronic  eroding  gastric  ulcer,  in  contradistinction 
to  the  acute  ulcers  produced  by  the  action  of  corrosive  poisons, 
which  have  already  been  discussed  in  speaking  of  toxic  gastritis  [see 
Chapter  lY].  The  name  chronic  round  gastric  ulcer  is  also  not 
quite  proper,  inasmuch  as  it  is  occasionally  acute  or  subacute,  and 
as  it  is  by  no  means  always  round,  but  frequently  of  various  forms. 

Etiology. — Investigators  have  zealously  endeavored  both  clinic- 
ally and  experimentally  to  establish  the  causes  of  gastric  ulcer. 
Synchronous  with  the  commencement  of  the  experimental  era  in 
medicine  is  the  first  careful  and  comprehensive  description  of  this 
affection  by  Cruveilhier,  who  was  the  first  to  raise  the  gastric  ulcer 
from  a  curiosity  of  the  autopsy  table  to  the  dignity  of  a  definite  and 
recognizable  pathological  condition. 

Experiments  on  Animals. — Gastric  ulcers — ^that  is,  circumscribed 
losses  of  tissue  in  the  mucous  membrane,  extending  to  the  submu- 
cous and  muscular  layers — ^may  be  produced  in  animals  by  various 


ETIOLOGY   OP  GASTRIC   UIiCER.  381 

means,  wliicli  in  tlie  end  always  amount  to  a  local  disturbance  of 
nutrition  in  limited  portions  of  the  mucous  membrane,  lasting  a  cer- 
tain time.  There  is  either  a  shutting  off  of  circumscribed  vascular 
areas  with  consequent  necrosis  and  sloughing  of  the  tissues,  the 
gastric  juice  meanwhile  attacking  the  spots  deprived  of  their  nor- 
mal nourishment  exactly  as,  under  favorable  conditions,  it  causes 
softening  (digestion)  of  the  dead  stomach,  but  to  a  greater  degree. 
This  is  due  to  emboh  artificially  produced,  ligation  of  small  vessels, 
or  to  haemorrhages  which  result  from  injury  to  certain  portions  of 
the  central  nervous  system.  Or,  the  ulcer  may  be  referred  to  direct 
mechanical,  chemical,  or  thermal  lesions  of  the  mucous  membrane, 
the  latter  being  at  the  same  time  accompanied  by  an  alteration  of 
the  circulation  in  the  parts  subjected  to  irritation.  But  these  losses 
of  substance  heal  with  exceptional  rapidity,  cicatrization  advancing 
from  the  margins  to  the  center  with  restoration  of  the  mucous 
membrane.  According  to  the  investigations  of  Griffini  and  Yas- 
sale,*  the  mucous  membrane  of  the  fundus  of  the  stomach  is  replaced 
by  the  formation  of  true  peptic  glands  from  the  superficial  epi- 
thelium which  at  first  covers  the  wound,  this  in  turn  being  formed 
from  the  glandular  epithelium  found  in  the  glands  situated  in  the 
margins  of  the  wound.  This  replacement,  too,  is  prompt  and  effi- 
cient, so  that  in  the  very  late  stages  of  the  process  it  is  difiicult  to 
find  the  situation  of  the  injury,  while  after  ten  to  fifteen  days  it 
has  entirely  healed,  without  leaving  behind  a  trace  of  its  presence. 
Thus,  these  are  fundamentally  acute  defects  of  the  mucous  membrane 
which  can  not  properly  be  called  ulcers ;  for  these,  at  least  during 
some  portion  of  their  existence,  must  display  the  tendency  to  spread. 
For  the  production  of  chronic  ulcers  another  force  must  come  into 
play — namely,  a  disproportion  must  exist  or  be  created  between  the 
secretion  of  the  gastric  glands  and  the  nutritive  blood,  either  syn- 
chronous with  or  previous  to  the  appearance  of  the  local  lesion  ;  it 
may  be  either  an  increased  acidity  of  the  former  or  a  deterioration 
of  the  latter,  or  both  factors  may  be  present  at  the  same  time.     Eb- 


*  L.  Griffini  und  G.  Vassale.  Ueber  die  Reproduction  der  Magenschleiinhaut. 
Beitrage  zur  pathologischen  Anatomie,  etc.,  von  Zeigler  und  Nauwerck,  Bd.  iii, 
Heft  5,  p.  425. 


382  DISEASES  OF  THE  STOMACH. 

stein,*  making  use  of  a  discovery  of  Scliiff,  produced  gastric  lisemor- 
rhages  and  corroding  ulcers,  and  even  perforation,  by  injury  to  the 
anterior  corpora  quadrigemina.  We  may  well  assume  tliat  an  ex- 
cessive production  of  acid  secretion  took  place  liere,  perhaps  due  to 
the  cerebral  irritation.  Koch  and  Ewald,f  by  introducing  a  hyper- 
acid 0"5-per-cent  solution  of  hydrochloric  acid,  produced  deep 
ulcers  in  the  stomachs  of  animals  in  which  gastric  haemorrhages  had 
been  caused  by  section  of  the  spinal  cord,  according  to  Schiff's 
method.  Quincke  and  Daettwyler  :j:  made  the  animals  aneemic  by 
venesection.  Silbermann  *  caused  haemoglobin semia  by  means  of 
substances  which  disintegrate  the  blood-corpuscles.  Under  such 
circumstances  the  losses  of  substance  produced  by  the  above-men- 
tioned methods  heal  but  gradually  and  tardily,  or  they  may  go  on 
even  to  perforation,  as  occurred  in  one  of  Silbermann's  experiments. 
Then  only  have  the  experiments  on  animals  borne  any  analogy  to 
the  clinical  picture  of  gastric  ulcer.  Talma  ||  succeeded  in  pro- 
ducing softening  of  the  stomach  as  well  as  typical  gastric  ulcers  in 
rabbits  and  dogs  by  ligating  the  stomach  above  and  below — that  is, 
tying  the  oesophagus  just  above  the  cardia,  and  the  duodenum  be- 
tween the  pylorus  and  the  m^outh  of  the  common  bile-duct.  The 
result  of  this  was  a  stagnation  and  fermentation  of  the  contents  of 
the  stomach,  the  quantity  of  the  latter  being  more  or  less  increased 
by  the  persistent  secretion  of  the  gastric  juice.  In  this  way  the 
walls  of  the  stomach  were  rendered  so  tense  that  sharply  localized 
hsemorrhagic  infarctions  were  produced,  and  from  these  typical 
gastric  ulcers.  Talma  also  concludes  that  "  a  disturbance  of  nutrition 
must  precede  the  ulceration,  be  it  either  a  simple  anaemia  or  a  re- 
tardation in  the  movement  of  the  nutritive  lymph  ;  or,  finally,  more 
profound  changes  in  the  tissues  themselves." 

*  W.  Ebstein.  Experimentelle  Untersuchiingen  uber  das  Zustandekomraen  der 
Blutextravasate  in  der  Magenschleimhaut.    Arch,  fiir  exper.  Pathol.,  Bd.  iii,  p.  188. 

f  Ewald.  Klinik,  etc.,  I.  Theil,  3te  Aufl.,  p.  123.  I  must  say  that  we  did  not 
carry  on  our  experiments  in  the  above  sense,  although  they  correspond  entirely 
with  them. 

X  H.  Quincke  und  Daettwyler.  Correspondenzbl.  f.  Sehweizer  Aerzte,  1875, 
p.  101. 

*  0.  Silbermann.  Experimentelles  und  Kritisches  zur  Lehre  vom  Ulcus  ven- 
triculi  rotund.     Deutsche  med.  Wochensehr.,  1886,  No.  29,  p.  497. 

II  Talma.  Untersuchungen  uber  Ulcus  ventriculi  simplex,  Gastromalacie  und 
Ileus.     Zeitschr.  fiir  klin.  Med.,  Bd.  xvii,  p.  10. 


ETIOLOGY   OF   GASTRIC   ULCER.  383 

In  TTian,  too,  if  we  confine  ourselves  to  the  typical  ulcer  of  the 
stomach,  and  disregard  the  secondary  ulceration  of  carcinoma  or  of 
phlegmonous  gastritis,  we  have  to  record  a  twofold  course  of  gastric 
ulcer.  Constant  reference  is  made  to  the  fact  that  it  is  doubtlessly 
not  uncommon  for  ulcers  to  occur — that  is,  in  the  sense  of  the  de- 
fects of  the  mucous  membrane  described  above— which  never  reach 
the  point  of  manifesting  themselves  clinically,  or  which  do  not  pre- 
sent the  t}"pical  picture  of  ulcer  of  the  stomach,  but  which  give  rise 
only  to  indefinite  symptoms,  which  do  not  spread  and  which  do  not 
really  cicatrize.  To  this  category  belong  the  hsemorrhagic  erosions 
of  Rokitanski,  which  were  already  regarded  by  him  as  the  initial 
steps  leading  to  true  gastric  ulcer.*  Here  I  might  also  include  the 
so-called  follicular  ulcers,  which  are  due  to  the  swelling  and  con- 
secutive suppuration  of  the  glandular  follicles.  The  factors  enu- 
merated above  often  give  rise  to  such  processes.  We  need  only 
think  of  the  frequent  occurrence  of  circumscribed  hasmorrhages 
from  the  mucous  membrane  in  chronic  catarrh,  especially  in  drink- 
ers ;  of  the  irritations  of  the  mucous  membrane  caused  by  too  hot 
ingesta,  and  of  the  artificial  lesions  produced  in  this  membrane  by 
the  introduction  of  sounds,  to  have  a  full  quota  of  such  factors.  In 
proof  of  this — the  transient  haemorrhages  and  follicular  suppuration 
due  to  irritating  ingesta — we  possess  a  classical  witness  for  all  time 
in  the  Canadian  experimented  on  by  Beaumont. f  Is  it  to  be  ex- 
pected in  the  many  cases  in  which  sharp  objects,  such  as  sjDlinters 
of  bone,  knife  and  dagger  blades,  etc.,  are  accidentally  or  purposely 
swallowed,  that  they  will  always  pass  off  without  lesion  to  the  wall 
of  the  stomach  ?     And  yet  ulcers  of  the  stomach   are  among  the 

*  C.  V.  Rokitanski.     Lehrbuch  der  pathol.  Anatomie,  3te  Aufl. 

f  W.  Beaumont.  Experiments  and  Observations  on  the  Gastric  Juice  and  the 
Physiology  of  Digestion.  Boston,  1833,  p.  108.  The  passage  in  these  excellent  in- 
vestigations, referred  to,  reads  as  follows  :  "  There  are  sometimes  found  on  the  in- 
ternal coat  of  the  stomach  (especially  after  irritation  of  the  mucosa  by  food)  erup- 
tions, or  deep-red  pimples ;  not  numerous,  but  distributed  here  and  there  upon  the 
villous  membrane,  rising  above  the  surface  of  the  mucous  coat.  These  are  at  first 
sharp-pointed  and  red,  but  frequently  become  filled  with  white  purulent  matter. 
At  other  times  irregular  circumscribed  red  patches,  varying  in  size  and  extent 
from  half  an  inch  to  an  inch  and  a  half,  are  found  on  the  internal  coat.  These 
appear  to  be  the  effect  of  congestion  in  the  minute  blood-vessels  of  the  stomacl). 
There  are  also  seen  at  times  small  aphthous  crusts  in  connection  with  these  red 
patches." 


384  DISEASES  OF   THE  STOMACH. 

rarer  results.  One  of  tlie  most  remarkable  examples  of  this  kind, 
and  at  the  same  time  a  most  striking  proof  of  what  the  stomach 
may  be  subjected  to,  is  the  following  very  curious  case  of  the  sailor, 
John  Gumming,  reported  by  Dr.  Marcet :  * 

In  the  year  1799  an  American  sailor  saw  a  juggler  in  Havre  perform 
the  trick  of  knife-swallowing.  Returning  to  his  vessel  somewhat  intoxi- 
cated, he  was  foolhardy  enough  to  try  to  swallow  his  open  pocket-knife, 
and  succeeding  in  this,  he  "  ate  "  three  more.  Three  passed  off  in  the 
stool  during  the  next  few  days,  but  one  could  not  he  accounted  for. 
One  evening,  six  years  later,  he  again  swallowed  six  knives,  but  this 
time  not  without  unpleasant  though  very  transient  results,  on  account  of 
which  he  was  admitted  to  a  hospital.  He  did  this  frequently,  till  he  had 
swallowed  about  thirty-five  knives.  Finally  he  was  taken  seriously  ill, 
and  died  in  Gruy's  Hospital,  in  London,  in  1809.  In  the  stomach  some 
thirty  pieces  of  blades,  in  parts  markedly  corroded,  together  with  handles, 
were  found ;  two  blades  in  the  colon  and  rectum,  which  were  placed 
transversely  and  had  perforated  the  intestinal  wall  (and  that  without 
causing  peritonitis),  but  no  recent  or  old  ulcers  of  the  stomach,  or  any 
remains  of  tbem. 

It  is  inconceivable  that  the  man's  repeated  onslaughts  on  the 
mucous  membrane  of  his  stomach  should  have  passed  off  without 
producing  any  lesion  at  all ;  yet  he  nevertheless  acquired  no  gastric 
ulcer.  Moreover,  it  is  also  recorded  that  to  the  end  he  always  en- 
joyed good  health,  and  that  he  had  a  very  good  appetite. 

If,  therefore,  gastric  ulcer  always  resulted  from  the  injuries 
above  mentioned,  it  would  appear  much  more  frequently  than  is 
observed ;  in  fact,  it  would  he  the  rule,  and  its  absence  the  excep- 
tion. Let  us  take,  for  instance,  the  frequently  mentioned  occurrence 
of  ulcer  in  cooks.  It  is  true  that  their  employment  affords  them 
ample  opportunity  to  swallow  hot  morsels.  Becker  f  has  succeeded 
in  experimentally  producing  gastric  ulcers  in  dogs  by  introducing 
hot  gruel  into  their  stomachs.  But,  not  to  speak  of  cooks,  how 
many  persons  eat  their  food  hastily,  and  as  hot  as  possible,  without 
acquiring  gastric  ulcer ;  and  how  small  is  the  percentage  of  cooks 
who  suffer  with  ulcer  in  comparison  to  the  entire  number  of  the 
members  of  this  honorable  craft !  On  the  other  hand,  we  actually 
know  of  cases  in  which  ulcers  were  due  to  traumatisms.     Leube  :j: 

*  Marcet.     Med.-Chirurg.  Transactions,  vol.  xii,  p.  73. 
f  Becker.     Bed.  kiln.  Wochensehr.,  1887,  p.  369. 
i  Leube.     Centralbl.  f  iir  klin.  Med.,  1886,  No.  5. 


ETIOLOGY   OF   GASTRIC   ULCER.  385 

describes  under  the  name  of  ulcus  ventriculi  traumaticum  a  typical 
case  of  an  ulcer  developed  after  a  blow  upon  the  epigastrium  by  the 
tongue  of  a  wagon,  ii^  a  man  who  had  always  been  healthy,  and. 
who  remained  perfectly  well  after  the  ulcer  was  healed.  Yanni  * 
also  reports  the  case  of  a  woman,  thirty-two  years  of  age,  in  whom 
all  the  symptoms  of  a  typical  gastric  ulcer  developed  unmediately 
after  a  blow  upon  the  epigastrium.  The  same  author  has  collected 
fourteen  reported  cases  of  round  ulcer  of  traumatic  origin.  In  this 
category  we  may  also  include  the  cases  described  by  Tahna,f  in 
which  hsemorrhages  of  the  stomach  and  ulceration  resulted  from 
severe  general  convulsions.  But  how  many  persons  have  had  con- 
vulsions and  received  blows  upon  the  stomach  without  developing 
ulcers !  [After  having  made  careful  autopsies  on  three  cases  of 
severe  internal  injuries,  Midler :}:  maintains  that  traumatisms  may 
cause  gastric  and  duodenal  ulcers.] 

Changes  iii  the  Blood. — Evidently  here,  as  well  as  in  the  examples 
given  above,  there  must  be  a  second  factor  in  order  to  render  pos- 
sible the  chronic  development  of  the  supposed  injury  and  its  sequelae 
— a  factor  which  to  a  certain  extent  forms  the  basis  on  which  the 
ulcer  can  Kar  ^^oyjqv  develop.  And  it  is  only  by  means  of  such  a 
permanent  or  transient  "  predisposition "  that  the  much-discussed 
question,  why  some  ulcers  heal  and  others  progress,  can  be  solved. 
There  is  no  lack  of  analogies  for  such  a  condition.  I  need  only 
bring  forward  the  example  of  the  tubercle  bacilli  which  is  now  so 
familiar  to  all.  Here,  too,  there  is  the  exciting  poison,  the  bacillus, 
to  which  numberless  persons  are  exposed  on  countless  occasions. 
However,  to  become  tuberculous,  the  predisposition  is  requisite, 
which  fortunately  is  not  the  possession  of  everybody.  In  man  this 
predisposition  to  gastric  idcer  resides  in  the  disproportion  existing 
between  the  composition  of  the  gastric  juice  and  the  lHood,  as  we 
have  already  recognized  it  as  necessary  for  the  artificial  production 
of  chronic  ulcer  of  the  stomach  in  animals.  It  is  not  the  alkalinity 
of  the  blood  which  prevents  the  autodigestion  of  the  gastric  mucous 

*  Vanni.  Sull'  uleera  dello  stomaco  d'  origine  traumatico.  Lo  Sperimentale, 
Juglio,  1889. 

f  Loc.  cit. 

X  [Miiller.  Ulcus  ventriculi  et  duodeni  traumaticum.  Inaug.  Dissert.,  Leipzig, 
1894,— Ed.] 


386  DISEASES  OP   THE   STOMACH. 

membrane  and  the  subsequent  development  of  a  round  ulcer,  ae 
stated  by  Pavj  *  in  his  explanation  at  that  time,  which,  deceptive 
by  its  simplicity,  was  therefore  almost  universally  accepted ;  for  the 
old  teaching  that  the  alkaline  condition  of  the  deeper  layers  of  the 
gastric  mucous  membrane  prevents  its  digestion  by  the  gastric  juice 
under  normal  conditions  is  untenable.  Disregarding  the  fact  that 
this  does  not  explain  why  the  upper  layers  of  the  mucosa  (which,  as 
is  well  known,  have  an  acid  reaction)  are  not  digested,  Edinger  has 
endeavored  to  prove  that  the  deeper  layers  are  also  acid.f  And 
even  if  we  are  unwilling  to  ascribe  much  weight  to  these  experi- 
ments, as  I  have  proved  in  the  place  cited  below,  it  is  nevertheless 
true  that  the  alkaline  reaction,  as  such,  does  not  suffice  here — alkali 
albuminates  are  also  digested — because  the  blood  may  be  made  neu- 
tral by  means  of  acid,  as  Samuelson  j^  has  shown,  and  yet  not  lead 
to  autodigestion  of  the  stomach. 

This  investigator  gives  still  more  important  reasons,  and  refers 
especially  to  the  contradiction  that  the  acid  formed  in  the  glands  is 
not  neutralized  when  it  enters  the  cavity  of  the  stomach,  but  that 
this  is  supposed  to  occur  when  the  reverse  takes  place — i.  e.,  when 
the  acid  is  brought  in  contact  with  the  mucous  membrane.  There- 
fore, either  no  free  alkali  exists  in  the  neighborhood  of  the  acid,  or 
it  can  no  more  neutralize  the  excreted  than  it  can  the  penetrating 
acid.  Furthermore,  Sehrwald  *  has  shown  that  in  a  living  anima 
the  diffusion  of  an  alkali  through  the  wall  of  the  stomach  into  ar,. 
acid  solution  which  had  been  poured  into  its  cavity  proceeds  far 
differently  than  in  a  stomach  removed  from  the  body,  taking  place 
much  more  energetically  in  the  latter  than  in  the  former  case.  This 
is  a  remarkable  phenomenon,  which  can  only  be  explained  by  the 
influence  of  the  living  cell  on  the  course  of  the  physical  process. 
Further,  how  is  it  that  an  ulcer  heals  in  spite  of  the  damage  done  to 
the  protecting  network  of  vessels  ?     Why,  for  instance,  does  not  the 

*  Pavy.     On  Gastric  Erosion.     G-uy's  Hosp.  Reports,  siv,  1868. 

f  Edinger.  Ueber  die  Reaction  der  lebenden  Mag'enschleimha.ut.  Pfluger's 
Areiiiv,  Bd.  xxix,  S.  247.     See  Ewald.     Klinik,  etc.,  I.  Theil,  3te  Aufl.,  S.  121. 

X  Samuelson.  Die  Selbstverdauung  des  Magens.  Preyer's  Sammlung  physiol. 
Abhandl.,  1879.    II.  Reihe,  Heft  6. 

^^  E.  Sehrwald.  Was  verhindert  die  Selbstverdauung  das  lebenden  Magens? 
Miinchener  med.  Wochensehr.,  1888,  No.  44  und  45. 


ETIOLOGY  OF   GASTRIC   ULCER.  387 

pancreas  digest  itself  ?  This  problem  still  lies  before  us,  for  our 
knowledge  of  the  zymogens  can  not  solve  it,  and  we  are  no  nearer 
the  solution  even  after  recognizing  "  the  vital  energy  of  the  cells  " 
or  Hunter's  "  living  principle." 

We  must  cling  to  the  fact  that  normal  gastric  juice  and  normal 
blood  do  not  cause  the  formation  of  an  ulcer  from  the  factors  already 
discussed,  nor  do  they  further  its  course  or  prevent  its  healing.  The 
disproportion  ietween  the  acidity  of  the  gastric  juice  and  the  com- 
position of  the  Mood  is  always  necessary  to  produce  such  a  result. 

Modern  Views. — The  exact  grounds  for  the  view  proposed  above 
have,  it  is  true,  been  arrived  at  only  by  the  more  recent  investiga- 
tions. We  have  known  for  a  long  time  that  corroding  gastric  ulcers 
arise  from  anomalies  in  the  composition  of  the  blood.  Suppression 
of  the  menses,  chlorosis,  anaemia  after  parturition,  are  seen  too  fre- 
quently in  connection  with  gastric  ulcer  to  admit  of  any  doubt  as  to 
their  etiological  relations.  Indeed,  Miquel  *  reports  cases  in  which 
menstruation  at  first  ceased  and  then  returned  again ;  but  a  reap- 
pearance of  the  gastralgia  with  increased  severity  was  noticed  at 
every  menstrual  epoch.  Crisp,f  in  his  time,  collected  fourteen  cases 
of  perforating  gastric  ulcer  in  women,  in  thirteen  of  which  there  was 
coexisting  irregularity  or  absence  of  menstruation.  On  the  other 
hand,  W.  Fox,:}:  supported  by  the  observation  of  a  case  of  poisoning 
by  hydrochloric  acid  with  perforating  ulcer,  had  already  expressed 
his  suspicion  that  the  cause  of  the  formation  of  an  ulcer  might  be 
"  excessive  secretion  or  excessive  acidity  of  the  gastric  juice,  espe- 
cially when  the  stomach  was  empty."  But  the  exact  proof  that  the 
ulcers  are  in  many  cases  associated  with  hyper chlorhydria  of  the  gas- 
tric juice  was  first  brought  forward  by  the  investigations  of  Yon  den 
Yelden,  Eiegel,  Ewald,  Jaworski,  Boas,  Eosenheim,  and  others. 
The  primary  cause  of  the  ulcer  may  then  be  one  of  the  above-men- 
tioned accidents.  These  include  traumatic  or  thermal  irritations, 
violent  emesis,  haemorrhages  due  to  congested  conditions,  hyper- 
semia  and  stasis  in  circumscribed  vascular  areas  of  the  mucous  mem- 


*  Miquel.     Hannover.  Zeitschr.  f.  prakt.  Heilkunde. 
f  Crisp.     On  Perforation  of  the  Stomach.     Lancet,  August  5, 1843. 
X  W.  Fox.     Chronic  Ulcer  of  the  Stomach.     Reynolds's  System  of  Med.,  vol.  ii, 
p.  930. 


388  DISEASES   OP  THE   STOMACH. 

brane,  hsemorrliagic  infarctions,  spasm  of  the  vessels,  and  atherom- 
atous, amyloid,  or  aneurismal  degeneration.  But  such  injuries 
are  undoubtedly  of  frequent  occurrence  in  the  stomach  without 
being  followed  by  ulcer.  If,  however,  a  growing  ulcer  develops,  it 
is  due  to  the  existence  of  one  or  another  of  the  anomalies  men- 
tioned. Repair  begins  only  when  the  latter  has  been  removed ; 
then  a  reactive  inflammation  of  the  base  of  the  ulcer  and  of  the 
surrounding  tissues  sets  in,  and  its  subsequent  cicatrization  becomes 
possible. 

Here,  too,  lies  the  natural  explanation  of  the  well-known  tend- 
ency of  gastric  ulcers  to  relapse.  According  to  my  conception,  re- 
lapses  always  follow  in  those  cases  in  which  the  underlying  affection 
is  i/roMsiently  relieved  hy  therapeutic  measures,  hut  which  returns  to 
the  old  condition  as  soon  as  the  effect  of  the  medication  wears  off. 
This  also  corresponds  with  the  well-known  fact  that  the  greatest 
contingent  of  relapsing  gastric  ulcers  is  drawn  from  those  of  a  nerv- 
ous or  chlorotic  nature,  whose  cure  requires  a  long  time,  and  in 
whom  the  tendency  to  relapse  is  well  marked. 

Perhaps  the  objection  may  be  raised  that  many  diseases  in  which 
there  is  alteration  of  the  composition  of  the  blood  predispose  to  gas- 
tric haemorrhage  without  the  occurrence  of  typical  gastric  ulcers. 
Thus,  for  instance,  in  cirrhosis  of  the  liver  haemorrhages  from  the 
gastric  mucous  membrane  due  to  obstruction  in  the  portal  circula- 
tion are  not  uncommon,  yet  the  occurrence  of  gastric  ulcers  is  only 
a  simple  coincidence.  My  answer  is,  that  these  processes  reduce  the 
acidity  of  the  secretion  by  means  of  the  consecutive  hyperaemic  and 
catarrhal  condition  of  the  mucosa.  Consequently,  the  requisite  dis- 
proportion between  the  blood  and  the  gastric  juice  does  not  exist, 
even  though  both  components,  taken  absolutely,  are  found  to  be  al- 
tered. As  predisposing  factors,  however,  we  must  recognize  hyper- 
acidity of  the  gastric  juice,  produced  by  hyperchlorhydria,  as  well 
as  a  cha/nge  in  the  composition  of  the  Mood  in  the  presence  of  the 
normal  acidity. 

Riegel  and  Talma  believe  that  this  hyperchlorhydria  is  the  un- 
derlying cause  and  ej95cient  agent  in  the  production  of  gastric  ulcers. 
Korcynski  and  Jaworski  claim  that  the  "  acid  gastric  catarrh  "  which 
they  have  described  and  which  we  have  already  mentioned  [page 


ETIOLOGY  OF  GASTRIC  ULCER.  389 

194]  is  the  cause,  and  maintain  that  "  ulcers  are  produced  as  tlie 
result  of  the  action  of  the  acrid  gastric  juice  upon  the  altered  mucosa 
of  the  pylorus."  But  why  should  there  be  circumscribed  necroses 
when  the  entire  membrane  is  changed  ?  Eiegel's  views  are  much 
more  acceptable  :  "  On  account  of  the  hyperchlorhydria  an  erosion 
or  injury  of  the  mucous  membrane,  unimportant  in  itself  and  tend- 
ing to  rapid  repair,  attains  a  greater  significance  ;  its  healing  is  re- 
tarded and  the  ulcer  spreads."  *  A  second  possibility,  and  one 
equally  justified,  is  this,  that  the  hyperchlorhydria,  and  with  it  the 
typical  ulcer,  is  only  developed  in  predisposed  individuals  with  great 
irritability  of  the  nerves  of  secretion,  as  the  result  of  some  damage, 
etc.,  to  the  mucous  membrane.  In  other  words,  as  Ritter  and 
Hirsch  also  say,  the  hyperchlorhydria  may  just  as  well  be  the  result 
as  the  cause  (or,  as  I  should  say,  the  primary  predisposing  factor)  of 
the  ulcer. 

The  idea  that  the  secretion  of  hyperacid  gastric  juice  is  essential 
for  the  formation  of  a  round  ulcer  is  by  no  means  new,  but,  like  all 
the  questions  with  which  the  pathology  of  the  stomach  has  recently 
been  concerned,  was  expressed  long  ago,  even  if  it  was  not  investi- 
gated by  means  of  exact  methods.  It  is  closely  connected  with  the 
question  of  softening  of  the  stomach — gastromalacia — which,  unless 
it  be  a  post-mortem  phenomenon,  is  nothing  but  a  large  gastric 
ulcer  running  an  acute  course.  Even  Rokitanski  and  Camerer 
believed  that  hyperacid  gastric  juice  was  secreted  in  these  cases 
as  a  result  of  a  paralysis  of  the  vagi.  Giinsburgf  directly  pos- 
tulated that  the  existence  of  a  perforating  gastric  ulcer  depended 
upon  the  production  of  a  hyperacid  secretion.  He  says,  "  The 
(ulcerative)  destruction  of  the  gastric  mucous  membrane  depends 
upon  a  quantitative  irregularity  in  the  secretion  of  free  acid."  His 
chief  evidence  was  the  fact  that  in  perforating  ulcer  he  found  the 
mucus  of  the  stomach  markedly  acid,  instead  of  its  having  the 
usual  alkaline  reaction ;  he  erred  in  referring  this  hyperacidity  to 
lactic  acid,  in  accordance  with  the  view  then  held  as  to  the  nature 

*  P.  Riegel.  Ziir  Lehre  vom  Ulcus  ventriculi  rotundum.  Deutsche  med.  Woch- 
enschr.,  1886,  No.  53,  S.  931. 

\  Fr.  Giinsburg.  Zur  Kritik  des  Magengeschwurs,  insbesondere  des  perforiren- 
den.    Arch.  f.  physiol.  Heilkunde,  xi.  Jahrg.,  1852,  S.  516. 


390  DISEASES  OF  THE  STOMACH. 

of  the  acid  of  tlie  gastric  jnice.  However,  it  can  nevertheless  be 
seen  that  here,  as  well  as  everywhere  else,  we  stand  on  the  shoul- 
ders of  our  j)redecessors,  and  that  the  numerous  public  and  private 
claims  for  priority,  on  closer  investigation,  shrink  to  very  modest 
proportions. 

The  remarkable  coincidence  of  burns  of  the  skin  with  ulcers  of 
the  stomach  and  duodenum  in  young  subjects,  first  observed  by 
Curling,*  and  later  by  Dupuytren,  Cooper,  Erichsen,  Wilks,  and 
others,  will  be  no  more  than  mentioned  in  this  place,  inasmuch  as 
for  the  present  we  possess  no  knowledge  of  a  possible  interdepend- 
ence of  the  two  processes.  In  125  cases  of  severe  burns.  Holmes  f 
found  the  duodenum  ulcerated  in  16,  and  other  portions  of  the  in- 
testine in  2.  The  earliest  period  of  its  appearance  was  from  four 
to  six  days  after  the  burn.  A  possible  clue  to  understanding  this 
remarkable  phenomenon  has  been  furnished  by  W.  Hunter, :|:  who 
observed  duodenal  ulcers  surrounding  the  orifice  of  the  common  bile 
duct  after  subcutaneous  injections  of  toluylendiamide ;  he  believes 
that  the  ulcers  were  due  to  excretion  through  the  bile  of  substances 
which  may  provoke  inflammation.  It  is  possible  that  in  burns  some 
similar  substances  may  be  produced  by  decomposition  of  the  blood 
or  by  absorption  of  toxic  substances  from  the  burned  area  which  is 
then  excreted  in  the  bile.  Ulcers  in  the  stomach,  of  which  Koki- 
tanski.  Low,  Wilks,*  and  Pitt  ||  report  cases,  seem  to  be  much  rarer. 

And,  finally,  micro-organisms  have  also  been  brought  forward 
as  the  cause  of  gastric  ulcer.  Botticher's  observations  on  this  sub- 
ject were  soon  shown  by  Korte"^  to  be  inconstant  and  not  con- 
vincing.     Letulle^  found   numerous  streptococci  in  the  veins  of 

*  Curling.  On  Acute  Ulceration  of  the  Duodenum.  Med.-Chirurg.  Transact., 
vol.  XXV,  p.  260. 

f  Holmes.    Syst.  of  Surgery,  vol.  i,  p.  733. 

X  W.  Hunter.  The  Pathology  of  Duodenitis.  Transact.  Patholog.  Society  of 
London,  1890. 

*  Wilks.  Cases  of  Death  from  Burns  and  Scalds.  Case  77,  quoted  by  Falk. 
Ueber  einige  Allgemeinerscheinungen  nach  umfangreichen  Hautverbrenmmgen. 
Virchow's  Arch.,  1871,  Bd.  liii,  p.  37. 

II  Pitt.  Stomach  with  Numerous  Superficial  Erosions  following  after  an  Exten- 
sive Burn.     Transact.  Pathol.  Soe.  London,  1887,  pp.  38,  140. 

^  Korte.  Beitrage  zur  Lehre  vom  runden  Magengeschwiirs.  Inaug.  Dissert., 
Strassburg,  1875. 

^  M.  LetuUe.  Origine  infectieuse  de  certains  uleeres  simples  de  I'estomac  ou  du 
duodenum.     Compt,  rend.,  torn.  106,  No.  35. 


OCCURRENCE   OF  GASTRIC   ULCER.  391 

the  siibmucosa  and  of  the  uterus  in  a  case  of  recent  ulcer  of  the 
stomach,  which  appeared  during  the  course  of  puerperal  septicaemia. 
Pure  cultures  of  these  injected  into  guinea  pigs  also  caused  ulcera- 
tions in  the  stomachs  of  the  animals,  which  threatened  to  perforate 
the  walls  of  the  artificially  distended  organ.  Letulle  obtained  the 
same  result  in  four  cases  with  the  staphylococcus  pyogenes  aureus 
cultivated  from  various  abscesses,  and  in  one  case  with  the  microbes 
of  dysentery  discovered  by  Chantemasse  and  Widal ;  in  this  case  they 
were  derived  from  a  man  who  had  returned  from  Cochin-China 
with  chronic  dysentery,  and  was  attacked  with  a  gastric  ulcer.  It 
was  claimed  that  the  process  was  either  embolism  or  direct  invasion 
of  the  mucous  membrane,  leading  to  necrotic  spots  and  the  diges- 
tion of  circumscribed  areas.  For  the  present  the  simple  recording 
of  these  statements  will  suffice.  [The  latest  advocate  of  the  microbic 
origin  of  gastric  ulcers  is  Martin.*  The  general  tendency,  how- 
ever, is  against  accepting  any  etiological  relation  of  bacteria.  The 
presence  of  numerous  micro-organisms  in  ulcers  means  nothing. 
On  the  other  hand,  there  is  no  doubt  that  some  ulcers  are  caused  by 
bacteria  being  transported  by  the  blood  and  causing  thrombosis. 
Such  ulcers  may  occur  in  sepsis,  acute  rheumatism,  possibly  tuber- 
culosis and  other  infectious  diseases.f     (See  also  page  183.)] 

So  much  concerning  the  presumable  cause  of  ulcers  of  the  stom- 
ach. I  have  spoken  of  these  views  first  because  at  present  they  are 
the  center  of  interest,  and  because  they  are  naturally  of  great  im- 
portance in  prognosis  and  therapy.  I  shall  now  review  the  clinical 
facts. 

I  shall  first  give  a  few  statistics,  which,  as  they  are  compiled 
from  the  records  of  autopsies,  naturally  refer  only  to  the  typical 
perforating  or  cicatrizing  ulcers. 

Occurrence. — The  frequency  of  ulcer  of  the  stomach  seems  to 
vary  in  different  localities.  Lebert,  it  is  true,  holds  that  on  the 
average  this  is  between  4  and  5  per  cent  [of  the  total  mortality]  for 
Europe,  and  supports  this  statement  by  his  own  statistics  as  well  as 
those  of  Brinton  and  Jaksch  ;  yet  these  averages  are  subject  to  con- 

*  [Martin.    Diseases  of  the  Stomach,  1895,  p.  418.— Ed.] 
t  [Rosenheim.     Op.  cit,  p.  350.— Ed.] 
26 


392  DISEASES  OP  THE  STOMACH. 

siderable  variations.  Disregarding  the  fact  that  the  figure  estimated 
by  Lebert  for  Jaksch's  statistics  at  5"8  per  cent  is  incorrect,  and 
should  be  3-2  per  cent,  we  find  that  Berthold  gives  2'Y  per  cent  for 
Berhn,  and  ]Srolte  1'23  per  cent  for  Munich ;  while,  on  the  other 
hand,  Griess  gives  8*3  per  cent  for  Kiel,  in  Jena  it  is  said  to  be  10 
per  cent ;  according  to  Starck,  it  is  13  per  cent  in  Copenhagen.* 
[Fiedler  f  states  that  in  2,200  autopsies,  ulcers  or  scars  were  found 
in  1*5  per  cent  of  the  men  and  20  per  cent  of  the  women.]  Inas- 
much as  these  results  are  deduced  from  large  numbers,  it  is  to  be 
supposed  that  the  unimportant  errors  have  become  fairly  well  aver- 
aged, and  that  a  certain  regional  difference  is  exhibited.  There  is 
nothing  surprising  in  this,  for  the  causes  of  ulcer  of  the  stomach  are 
in  part  referable  to  direct  irritation  of  the  gastric  mucous  mem- 
brane, and  this  factor  changes  with  the  mode  of  life  and  the  food 
supply  in  the  various  places.  It  has  frequently  been  shown  that  an 
insufiicient  diet  may  cause  gastric  ulcer,  as  demonstrated,  for  in- 
stance, by  Gerhardt's  experiences  in  Thiiringen.  Sohlern,:}:  pro- 
ceeding the  opposite  way,  has  lately  called  attention  to  the  fact  that 
m  certain  districts  of  Germany,  the  Rhon  Mountains  and  the  Ba- 
varian Alps,  and  further  in  the  greater  part  of  Russia  (the  so-called 
Grossrussland\  gastric  ulcer  is  a  rarity,  and  that,  strange  to  say,  the 
inhabitants  of  these  regions  exist  almost  exclusively  on  a  vegetable 
diet.  J^evertheless,  this  class  of  people,  especially  in  Russia  and 
Bavaria,  is  in  general  well  nourished  and  strong.  N^ow,  as  it  is 
well  known  that  much  more  potassium  is  added  to  the  blood  on  a 
vegetable  diet,  nearly  a  third  more  than  on  a  mixed  diet,  so  this 
permanently  increased  addition  necessarily  brings  with  it  an  in- 
crease in  the  amount  of  this  metal  in  the  blood  ;  while,  according  to 
other  investigations,  the  red  blood-cells  are  to  be  regarded  as  the 
chief  carriers  of  potassium.  Sohlern  claims  that  this  increased 
amount  would  represent  the  cause  of  the  relative  immunity  of  the 

*  [As  Welch  properly  says,  such  statistics  are  based  upon  the  result  of  autopsies 
in  which  all  cicatrices  are  included  as  healed  ulcers.  The  ratio  of  cicatrices  to  open 
ulcers  has  been  placed  at  3  to  1. — Ed.J 

f  [Fiedler.  Sitzungsberieht  d.  Dresdener  Vereins  fiir  Natur  und  Heilkunde, 
1883.— Ed.] 

X  Von  Sohlern.  Der  Einfiuss  der  Ernahrung  auf  die  Entstehung  des  Magenge- 
schwiirs.     Berl.  klin.  Wochenschr.,  1889,  No.  14. 


OCCURRENCE   OF  GASTRIC    ULCER.  393 

above-mentioned  classes  from  ulcer  of  the  stomach,  quite  in  accord- 
ance with  the  rare  occurrence  of  this  disease  in  vegetarians,  whose 
blood,  as  is  well  known,  is  rich  in  potassium  phosphate.  On  the 
other  hand,  diseases  accompanied  bj  an  impoverishment  or  change 
in  the  red  blood-cells,  such  as  chlorosis,  ansemia,  etc.,  might  tend  to 
the  development  of  ulcer  because  they  produce  blood  which  is  poor 
in  potassium. 

For  the  present,  as  Sohlern  himself  says,  these  very  interesting 
considerations  lack  the  support  of  a  series  of  examinations  of  blood 
made  for  the  purpose ;  but  even  without  these  the  significance  of 
the  facts  advanced  can  not  be  denied. 

Statistics  show  great  unanimity  regarding  the  remainder  of  the 
accessible  factors — sex^  age,  site  of  the  ulcer,  and  frequency  of  per - 
f oration.  It  is  universally  found  that  females  are  more  frequently 
affected  than  males,  the  average  proportion  being  as  two  to  one. 
Further,  on  consideration  of  all  the  factors  involved,  it  is  without 
doiibt  that  it  most  commonly  occurs  between  the  ages  of  twenty  and 
forty,  while  the  greatest  mortality  is  found  between  forty  and  sixty 
years.  These  facts  are  in  no  way  altered  by  Griinf eldt  *  having 
found  scars  of  gastric  ulcers  92  times  (20  per  cent)  in  450  autopsies 
on  old  people,  or  by  Chiari's  f  case  of  a  recent  perforation  in  a  man 
seventy-one  years  old,  or  Sedgwick's:}:  similar  case  in  which  the 
man  was  eighty-two  years  old,  nor  by  the  fact  that,  according  to 
Birsch-Hirschfeld  and  Henoch,*  ulcers  of  the  stomach  are  fairly 
frequent  in  children,  and  even  in  the  newborn.  The  latter,  at  all 
events,  have  nothing  in  common  with  typical  gastric  ulcer,  inasmuch 
as  they  are  probably  caused  by  intra-uterine  poisons,  or  by  those 
connected  with  parturition,  and  since  they  do  not  last  beyond  earli- 
est infancy.  At  any  rate,  on  reference  to  the  mortality  tables,  we 
find  that  childhood,  till  the  tenth  or  fifteenth  year,  is  practically 
entirely  exempt.  On  the  other  hand,  I  think  it  very  probable  that 
ulcers  of  the  stomach  occur  at  this  age,  but  that,  owing  to  the  more 


*  Griinfeldt.     Hospitaltid,  2.  R.  ix,  p.  765,   quoted  in  Virchow-Hirsch's  Jahrb., 
1878. 

f  Chiari.     Fall  von  Perforation   eines  Magengeschwiirs.     Anzeiger  der  k.  k. 
Gesellsch.  d.  Aerzte  zu  Wien,  1880.  S.  161. 

X  Sedgwick.     On  Perforating  Ulcer  of  the  Stomach.     Dublin  Hosp.  Gaz.,  1855. 

*  Henoch.     Vorlesungen  uber  Kinderkrankhciten.     Berl.,  1883,  2te  Aufl.,  S.  61. 


394  DISEASES  OP  THE  STOMACH, 

active  regenerative  and  plastic  powers  of  the  tissues  in  childliood, 
the  tendency  to  recovery  is  greater  than  at  a  more  advanced  age.  I 
have  observed  at  least  two  cases  which  I  could  only  regard  as  gastric 
ulcer,  and  in  which  nothing  but  haemorrhage  was  needed  to  com- 
plete the  typical  picture.  Unquestionably,  however,  they  are  of 
much  rarer  occurrence  than  in  later  years,  because  the  injurious 
factors  are  far  less  common  in  childhood.  [A  number  of  cases 
of  ulcers  in  very  young  children  have  recently  been  pubhshed,  of 
which  I  shall  only  quote  the  case  reported  by  Colgan,*  in  a  child 
two  and  a  half  years  old.  The  patient  was  suddenly  attacked  with 
convulsions,  the  temperature  rose  to  106°,  the  pulse  to  150 ;  death 
occurred  in  13  hours.  There  were  no  gastric  symptoms.  The  au- 
topsy showed  a  perforation  on  the  posterior  wall  of  the  stomach 
at  the  cardia  and  near  the  greater  curvature.] 

"Whether  occupation  plays  any  role  in  the  causation  of  round 
ulcer,  as  is  frequently  accepted,  appears  more  than  doubtful  to  me, 
according  to  what  I  have  said  at  the  beginning  of  this  chapter. 
]^evertheless,  I  will  again  mention  the  well-known  fact  of  its  fre- 
quent occurrence  in  female  servants,  and  especially  in  cooks.  In 
English  literature  insufficient  food  is  more  often  given  among  the 
causes,  and  we  also  find  a  parallel  drawn  between  it  and  the  oc- 
currence of  ulcers  of  the  cornea  in  cachectic  and  much  enfeebled 
patients. 

Pathological  Anatomy. — A  large  number  of  the  ulcers  undoubt- 
edly arise  from  direct  lesions  to  the  vessels  and  their  result,  hsemor- 
rhagic  infarction,  whether  it  be  that  the  primary  cause  lies  in  the 
obstruction  of  the  smallest  arterial  twigs  which  run  up  between  the 
glands  of  the  mucous  membrane  from  the  submucosa,  or  whether 
it  be  that  atheromatous,  amyloid,  or  aneurismal  degeneration  of  the 
vascular  walls,  cerebral  injuries,  or  even  simple  and  spasmodic  con- 
traction of  the  muscular  layers,  predispose  to  the  rupture  of  the 
vessels.  In  a  few  cases  Yon  Openchowskif  has  also  observed 
hyaline  degeneration  of  the  walls  of  the  smallest  vessels  in  the 

*  [Quoted  by  Weir  and  Poote.     Medical  News,  April  25,  1896.— Ed.] 
t  Von  Openchowski.    Zur  pathologischen  Anatomie  der  geschwiirigen  Processe 
im  Magendarmtractus.    Virchow's  Archiv,  Bd.  cxvii,  p.  347. 


PATHOLOGICAL  ANATOMY   OF  GASTRIC   ULCER.  395 

haeraorrhagically  infiltrated  area  of  the  mucosa,  and  regards  tliem  as 
being  the  causes  of  the  latter. 

But  these  causes  are  not  alone  sufficient,  because  numerous  cases 
occur,  especially  in  youthful  individuals,  in  which  no  indication 
either  of  disease  of  the  vessels  or  of  the  other  enumerated  factors 
exists.  Here  we  must  assume  that  the  ulcers  are  developed  from 
the  follicular  haemorrhages  and  the  hgemorrhagic  erosions  of  Roki- 
tanski,  which  in  a  small  way  represent  the  same  thing  that  hsemor- 
rhagic  infarctions  do  on  a  large  scale,  namely,  the  withdrawal  of 
the  normal  nourishment  from  small  areas  of  the  mucous  membrane. 
Carswell,  in  his  Atlas,*  pictures  an  exquisite  example  of  follicular 
haemorrhages  with  punctate  haemorrhages  in  the  mouths  of  the 
crypts  partly  surrounded  by  a  round  zone  of  extravasated  blood. 
In  a  stomach  the  mucous  membrane  of  which  was  suffused  with 
blood,  and  which  I  treated  very  soon  after  death  according  to  Hei- 
denhain's  method  (placing  small  pieces  of  tissue  immediately  in  ab- 
solute alcohol  which  must  be  frequently  changed,  and  staining  with 
hsematoxyhn  and  bichromate  of  potassium),  I  found  the  ducts  of  the 
glands  packed  full  of  red  blood-cells  to  beyond  the  neck — i.  e., 
doAvn  into  the  fundal  portions.  These  could  only  have  had  their 
origin  in  a  haemorrhage  on  the  surface  of  the  mucous  membrane, 
which  in  its  turn  could  only  have  come  from  the  fine  capillary  net- 
work (Henle)  situated  close  beneath  the  free  surface  of  the  mucous 
membrane.  Such  haemorrhages  may  be  due  to  a  very  unimportant 
stoppage  of  the  circulation,  or  to  a  traumatism,  etc.  They  develop 
into  haemorrhagic  erosions,  small  streaklike  or  rounded  losses  of 
substance  from  the  size  of  a  millet  seed  to  that  of  a  pea,  on  which 
at  times  a  blackish-brown  extravasation  of  blood  is  found,  together 
with  the  simultaneous  loosening  of  the  mucous  membrane.  Their 
number  is  very  variable,  being  sometimes  enormous,  especially  near 
the  pylorus,  so  that  the  stomach  appears  as  if  sown  with  them. 
From  the  erosion  the  typical  chronic  ulcer  is  developed.  But  cer- 
tainly not  from  every  erosion,  which,  as  Langerhans  f  has  properly 
claimed,  are  distinguished  from  ulcers  by  the  fact  that  they  are 

*  [Carswell.    Loc.  cit.~\ 

t  R.  Langerhans.     Ungewohnliche  Art  der  hamorrhagischen  Erosion  des  Ma- 
gens.     Virchow's  Archiv,  Bd.  cxxiv,  p.  273. 


396  DISEASES  OF  THE  STOMACH. 

irregularly  scattered  over  the  mucous  membrane  in  large  numbers 
and  coalesce,  whereas  ulcers  occur  singly  and  in  certain  localities 
only.  ^Nevertheless  Langerhaus  and  D.  Gerhardt*  give  carefully 
described  typical  examples  of  such  erosions  which  have  been  trans- 
formed into  classical  ulcers.  Gerhardt  also  shows  that  we  may 
also  include  among  these  the  small  ulcers  which  are  formed  by  the 
swelling  and  bursting  of  lymphatic  follicles. 

But  whether  the  causation  of  the  ulcer  be  due  to  one  or  the 
other,  it  can  nevertheless  never  be  regarded  as  an  "  ulcer,"  viewing 
it  from  the  standpoint  of  pathological  anatomy ;  it  is  rather  a 
"  progressive  necrosis  of  tissue,"  in  which  the  characteristic  feature 
of  an  ulcer,  "  the  proliferation  of  young  cellular  elements  which 
always  spreads  deeper  into  the  tissues,  and  continually  throws  more 
elements  to  the  surface,"  f  is  entirely  lacking.  The  ulcer  does  not 
grow  by  an  active  process  in  the  tissues  with  subsequent  necrosis, 
but  by  a  passive  one.  The  participation  becomes  active  only  on 
the  appearance  of  the  cellular  infiltration  which  leads  to  cicatri- 
zation. 

The  gross  anatomy  of  gastric  ulcer  and  its  consequences  I  can 
dispose  of  in  a  few  words.  Its  form,  like  a  funnel  or  crater,  is  well 
known;  the  margin  is  at  first  sharply  defined,  and  only  becomes 
thickened  and  wall-like  later  on.  There  is  not  a  medical  student 
who  does  not  know  Kokitanski's  classical  comparison,  that  an  ulcer 
looks  "  as  though  cut  out  with  a  punch,"  although  this  can  only  be 
applied  to  old  perforating  ulcers ;  while  among  the  others  are  found 
linear,  oval,  insular,  or  steplike  forms.  Usually  the  base  of  the 
ulcer  is  smooth,  or  with  only  a  few  inequalities,  but  occasionally  it 
is  covered  with  small  blood-clots  or  with  tenacious  greenish  or 
brownish  mucus. 

The  size  varies  considerably,  being  usually  that  of  a  10-pfennig 
piece  [5-cent  nickel]  to  a  mark  [silver  quarter-dollar].  Generally 
the  ulcer  observed  by  Cruveilhier,  16  centimetres  [6f  inches]  in 
length,  and  8*5  centimetres  [3f  inches]  in  width,  is  referred  to  as  a 
prodigy ;  but  I  have  found  a  case  described  by  Habershon  in  which 

*    D.  Gerhardt.     Ueber  geschwiirige   Processe  im  Magen.     Virehow's  Archiv, 
Bd.  cxxvii,  p.  85. 

t  Virchow.     Cellular  Pathologie,  4te  Aufl.,  p.  537. 


PATHOLOGICAL  ANATOMY  OP  GASTRIC   ULCER.  397 

the  process  involved  nearly  the  entire  surface  from  the  pylorus  to 
the  cardia. 

The  site  is  preferably  at  the  pylorus  and  the  greater  curvature, 
corresponding  to  the  most  dependent  portion  of  the  stomach  where 
the  gastric  juice  collects  in  the  erect  posture  ;  hence  Nolte  gives  the 
following  scale  of  frequency :  At  the  greater  curvature  22,  at  the 
pylorus  13,  anterior  wall  3,  posterior  wall  2,  cardia  1.* 

Langerhans's  statement  (Joe.  cit.)  that  the  typical  site  of  gastric 
ulcers  is  "  along  the  lesser  curvature  "  is  opposed  to  these  and  my 
own  experiences. 

Number. — In  the  majority  of  cases  only  one  ulcer  is  present ; 
more,  up  to  three  or  over,  are  rare.  However,  Lange  saw  so  many 
of  them  in  one  case  that  "  he  had  to  give  up  the  attempt  to  count 
them  all."  f 

Finally,  if  in  the  course  of  the  process  the  base  of  the  ulcer  be- 
comes thickened  and  like  a  plate,  and  the  margins  indurated  and 
wall-like,  and  if  its  site  be  such  that  the  spot  is  appreciable  on  pal- 
pation, it  can  on  this  account  convey  the  impression  of  an  ulcer- 
ating malignant  neoplasm,  as  I  shall  discuss  more  fully  later  on. 
If,  however,  the  ulcer  is  situated  either  in  the  region  of  the  pylorus 
or  of  the  cardia,  the  cicatrization  may  cause  stenosis  of  these  open- 
ings with  its  clinical  sequelae.  It  is  also  to  be  noted  that  at  times 
several  ulcers,  which  were  originally  distinct,  may  coalesce  and 
form  one  large  ulcer. 

*  [Welch,  as  the  result  of  the  analysis  of  793  cases,  gives  the  following: 

Lesser  curvature 288  (36-3  per  cent). 

Posterior  wall 235(29-6       "       ) 

Pylorus 95(12  "       ) 

Anterior  wall 69(8-7       "       ) 

Cardia 50(6-3       "       ) 

Fundus 29(3-7       "       ) 

Greater  curvature 27  (  3-4       "       ) 

Pepper's  System  of  Medicine,  vol.  ii,  p.  503.  Peptic  ulcers  may  also  occur  in  the 
lower  portion  of  the  oesophagus  (see  page  115)  or  in  the  upper  part  of  the  duodenum 
(see  page  432).— Ed.] 

f  Lange.  Deutsche  Klinik,  1860,  p.  90.  "  In  addition  to  this  (i.  e.,  the  perfo- 
rating ulcer)  there  was  not  only  an  immense  number  of  scars  of  various  sizes  and 
depths  all  over  the  walls  of  the  stomach,  but  also  such  a  quantity  of  uncicatrized 
ulcers,  some  extending  only  into  the  mucosa,  others  penetrating  even  into  the  mus- 
cularis,  some  flat,  some  in  the  shape  of  holes,  and  others  funnellike,  that  I  had  to 
give  up  the  attempt  to  count  them  all." 


398  DISEASES  OF  THE  STOMACH. 

In  micToscojpio  sections  througli  the  margin  of  a  recent  ulcer  the 
ducts  of  the  glands  are  seen  to  descend  troughlike  \inuldenfoTmig\ 
and  as  though  cut  off  toward  the  base  of  the  ulcer.  They  are  sim- 
ply eaten  away  or  digested  as  far  as  the  tissues  could  offer  no  re- 
sistance to  the  digestive  power  of  the  gastric  juice.  It  is  only  in 
older  ulcers  that  a  reactive  inflammation  sets  in  at  the  periphery, 
leading  to  the  formation  of  a  callous  margin.  Here  the  trabeculse 
between  the  remaining  ducts  are  thickened  and  in  part  placed  ob- 
liquely, a  condition  which  would  appear  to  be  analogous  to  a  dis- 
covery of  Witosowski's,  which  will  be  mentioned  directly.  As 
much  of  the  glandular  epithelium  as  is  present  in  the  f  undal  por- 
tions of  the  remaining  ducts  has  undergone  a  remarkable  change. 
In  the  place  of  the  peptic  cells  we  find  cuboidal  or  cylindrical  epi- 
thelium ;  they  are  shrunken  so  that  they  are  separated  both  from 
the  membrana  propria  and  from  one  another ;  their  nuclei  can  not 
be  recognized  by  staining,  and  their  contents  are  of  a  broken-down, 
light,  glassy  appearance,  which  reminds  one  most  of  hyaline  degen- 
eration. Single  ducts  have  undergone  cystic  degeneration.  The 
submucosa  is  decidedly  broader  and  thicker,  with  an  abundant  infil- 
tration of  small  cells,  and  with  a  rich  vascular  network  ;  the  bands 
of  muscular  fibers  of  the  muscularis  in  some  portions  are  separated 
by  connective  tissue  which  is  partly  fibrillar,  partly  torn  apart  in 
meshes,  and  in  other  portions  they  have  been  entirely  replaced  by 
it.  "We  see,  therefore,  that  the  necrotic  process  is  surrounded  in  its 
entire  extent,  both  at  the  margin  and  the  base,  by  a  zone  which  is 
the  seat  of  irritative  processes,  which  subsequently  lead  on  to  true 
cicatrization.  This  always  causes  the  firm  attachment  of  the  base 
of  the  ulcer  to  the  underlying  tissue,  and  the  inversion  of  the  mu- 
cous membrane  at  the  edge  into  the  substance  of  the  ulcer. 

Witosowski  *  claims  that  the  ducts  of  the  glands  situated  at  the 
margin  of  the  ulcer  become  bent  so  that  their  mouths  are  turned 
toward  the  ulcer,  and  thus  pour  their  secretion  directly  into  it.  He 
holds  that  a  corroding  ulcer,  which  always  develops  at  the  bottom 
of  the  furrows  produced  by  the  folds  of  mucous  membrane,  can 
only  be  formed  by  these  means  or  by  a  simultaneous  process  of  pro- 

*  Witosowski.  Ueber  das  Verhaltniss  der  produetiv  entzilndlichen  Processe  zu 
den  UlcerOsen  im  Mageu.    Virchow's  Arch.,  Bd.  xciv,  p.  542. 


PATHOLOGICAL  ANATOMY  OP  GASTRIC  ULCER.  399 

liferation  proceeding  from  the  submucosa.  The  former  is  for  the 
most  part  true,  and  can  be  explained  by  the  impeded  circulation  of 
the  parts.  I  have  never  seen  the  latter,  and  I  can  not  regard  the 
singular  theory  which  Witosowski  has  founded  upon  it  as  being 
open  to  discussion.  At  all  events,  in  old  ulcers  the  ducts  of  the 
glands  are  directed  toward  the  crater  of  the  ulcer,  as  has  been  stated 
by  Hauser,*  and  as  I  can  fully  corroborate,  but  it  is  only  because  the 
elasticity  of  the  muscular  coat  causes  it  to  retract  and  draw  away 
under  the  mucosa ;  however,  from  the  very  nature  of  things,  a  secre- 
tion from  these  ducts  is  no  longer  possible. 

In  the  interstices  we  always  find  a  profuse  small-celled  infiltra- 
tion, but  there  is  nothing  specially  characteristic  of  ulcer  in  this,  as 
it  is  found  in  all  processes  leading  to  inflammatory  irritation  of  the 
mucous  membrane,  from  a  mild  catarrh  to  an  acute  phlegmonous 
gastritis.  Korczynski  and  Jaworski  f  have  examined  pieces  of  gas- 
tric mucous  membrane  which  were  removed  from  the  vicinity  of  an 
ulcer  at  operations  on  three  cases,  and  in  one  case  they  studied  large 
pieces  which  were  obtained  after  death.  They  were  able  to  demon- 
strate an  inflammatory  condition  of  the  interglandular  tissue  as  well 
as  a  disappearance  of  the  peptic  cells  of  the  gasti'ic  tubules,  the 
parietal  cells  being  unaffected  ;  there  was  also  extensive  loss  of  the 
superficial  epithelium  of  the  mucosa.  They  therefore  conclude  that 
this  inflammatory — i.  e.,  catarrhal — affection,  which  is  in  many 
cases  accompanied  by  a  coincident  overproduction  of  HCl,  is  in 
many  cases  the  primary  cause  of  the  ulcer.  In  my  opinion  the  con- 
trary would  be  much  more  probable  ;  for  mucous  membranes  sur- 
rounding the  ulcer  is  liable  to  be  put  into  an  irritable  condition 
which  involves  it  to  a  variable  extent  and  intensity. 

The  results  of  the  necrotic  process  are  of  special  interest.  We 
must  distinguish  between — 

1.  Cicatrization.  Here  there  exists  a  marked  distinction  from 
the  ulcers  artificially  produced  in  animals ;  for,  while  these  heal 
with  restitution  of  the  normal  mucous  membrane, :|:  as   Cohnheim 


*  G.  Hauser.     Das  chronisehe  Magengeschwiir.     Leipzig,  1883. 
f  Loc.  cit.    Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  xlvii. 

X  After  careful  investigations  this  has  been  corroborated  by  Griffiui  and  Va- 
sale.    Ziegler's  Beitrage  zur  patholog.  Anatomie,  Bd.  iii. 


400  DISEASES  OP  THE  STOMACH. 

states,  and  as  I,  too,  have  found,  in  man  a  fibrous,  centrally  de- 
pressed scar  is  formed,  with  the  well-known  tendency  to  contrac- 
tion. This  leads  to  radiating  scars  and  to  distortion  of  the  gastric 
wall,  especially  if  a  fixed  point  has  been  established  by  previous 
adhesions  to  the  neighboring  organs.  Girdlelike  constrictions  of 
the  viscus  occur,  giving  it  the  form  of  an  hourglass  or  a  gourd 
[the  hourglass  stomach].  In  this  way,  if  the  scar  is  situated  in 
the  lesser  curvature,  the  pylorus  and  cardia  may  be  drawn  together 
to  such  a  degree  that  a  lead  pencil  can  scarcely  be  passed  between 
them.  Thus,  also,  very  peculiar  cicatricial  bands  may  be  formed, 
which  lead  to  the  formation  of  a  complete  sac,  of  which  Cruveil- 
hier  *  gives  an  excellent  drawing  in  his  Atlas. 

2.  Progressive  necrosis  and  corrosion.  If  cicatrization  does 
not  occur,  the  necrotic  process  continues  as  long  as  any  gastric 
juice  is  secreted,  finally  causing  its  own  cessation  by  means  of  the 
ensuing  complications.     These  are : 

id)  Corrosion  of  the  vessels.  Yessels  of  larger  or  smaller  cahber 
are  opened  according  to  the  site  of  the  ulcer  and  to  its  extension 
into  the  tissues.  The  slight  tendency  to  thrombosis  is  a  character- 
istic feature,  which  is  probably  connected  with  the  digestive  action 
of  the  gastric  secretion.  Among  the  larger  vessels  most  frequently 
aifected  are  the  gastric,  splenic,  and  pancreatic  arteries. 

(J)  Adhesions  to  neighboring  organs  and  perforation.  If  the 
necrosis  extends  to  the  serosa,  it  leads  either  to  a  reactive  inflamma- 
tion and  adhesion  to  surrounding  organs,  and  consequent  spread  of 
the  process  to  them ;  or,  where  circumstances  will  not  permit  this, 
to  a  direst  perforation  into  the  abdominal  cavity.  There  may  also 
be  secondary  perforations  into  the  pleural  or  pericardial  cavities 
through  the  corresponding  interposed  tissues.  According  to  the 
site  of  the  ulcer,  all  the  neighboring  organs,  liver,  gall  bladder,f 
pancreas,  spleen,  diaphragm,  heart,  lungs,  and  intestines  are  subject 
to  this  possibility.  At  times  it  may  produce  adhesions  among  or- 
gans situated  near  one  another  in  the  abdominal  cavity,  such  a  case 
being  described  by  Budd. 

Finally,  tubercular  and  syphilitic  ulcers  must  be  mentioned. 
*  hoc.  eit.,  20.  LiYrais,  PI.  6.  f  Habershon.    Lancet,  June  2,  1883,  p.  951. 


TUBERCULAR  ULCER  OF  STOMACH.  401 

Tubercular  Ulcers. — Thus  far  tliese  have  only  been  found  in  con- 
nection with  tubercular  lesions  in  other  organs.  They  are  charac- 
terized by  their  tliickened,  infiltrated,  wall-like  margins ;  the  base  is 
for  the  most  part  yellowish  and  granular.  They  are  pale,  and,  as 
seen  in  Eppinger's*  cases,  they  thus  present  a  sharp  contrast  to 
their  dark- colored  surroundings.  In  the  margins  and  base,  tubercu- 
lar nodules  with  their  characteristic  giant- cells  are  found.  There 
may  be  one  or  more  ulcers,  involving  only  the  mucosa  and  sub- 
mucosa,  or  extending  down  to  the  muscularis.  In  a  few  cases  (Lit- 
ten  f )  the  serous  coat  over  the  base  of  the  ulcer  is  strewn  with  mili- 
ary tubercles.  In  Litten's  case  the  ulcer  was  fairly  large — 4:"2x3"3 
centimetres  [l*7xl'3  inch].  The  edges  were  sharp  and  indurated, 
and  in  parts  swollen  and  infiltrated  with  blood.  The  rest  of  the 
digestive  tract  was  free  from  tubercular  ulcerations,  but  they  were 
found  in  the  larynx,  bronchi,  and  lungs.  A  similar  case  is  reported 
by  Talamon-Balzer,:};  another  by  Gilles-Sabourin,*  and  Eppinger  |1 
has  described  two  others.  [An  excellent  descri23tion  of  tubercular 
ulcer  of  the  stomach  will  be  found  in  a  paper  by  Musser,^  in  which 
he  describes  a  case,  a  negro  forty-four  years  of  age,  with  pulmonary 
phthisis  and  vague  gastric  symptoms ;  on  autopsy,  an  ulcer, 
1 J  X  3|-  inches,  was  found  in  the  stomach ;  the  ulcer  was  evidently 
tubercular,  and  contained  cheesy  matter,  as  well  as  miliary  tubercles 
in  the  base  and  in  the  submucosa  in  the  vicinity.  Tubercle  bacilli 
were  found  in  the  cheesy  masses ;  they  were  also  found  in  some 
other  cases  which  he  mentions.  Barbacci  ()  describes  a  similar  case 
in  which  there  were  isolated  tubercular  ulcerations  in  the  stomach, 
the  primary  tuberculosis  being  in  the  pharynx.  Most  of  the  cases 
reported  by  Musser  occurred  in  children.]    Nevertheless,  these  cases 


*  Eppinger.  Ueber  Tuberculose  des  Magens  und  Oesophagus.  Prager  med. 
Wochenschr.,  1881,  No.  51  imd  52. 

t  M.  Litten.    Ulcus  ventriculi  tuberculosum.  Virchow's  Archiv,  Bd.  Isvii,  S.  615. 

X  Talaraon-Balzer.  Phthisie  locale ;  ulcerations  tuberculeuses  de  I'estomac  et 
de  I'intestin.     Bull.  See.  anatom.,  1878,  p.  374. 

*Ibid.  II  Loc  cit. 

^  [J.  H.  Musser.  Tubercular  Ulcer  of  the  Stomach.  Philadelphia  Hospital  Re- 
ports, 1890,  vol.  i,  pp.  117-124. — Also,  Barlow.  Transactions  of  Patholog.  Society 
of  London,  1887,  vol.  xxxviii. — Ed.] 

t)  Barbacci.  Un  nuovo  case  di  tuberculosi  gastrica.  Lo  Sperimental,  1893, 
No.  13. 


4(>2  DISEASES  OF  THE  STOMACH. 

are  quite  rare,  since  Eisenhardt  *  found  only  one  case  of  gastric 
tuberculosis  in  567  cases  of  tuberculosis  of  the  intestines.  Marfan,f 
in  a  study  of  the  gastric  disturbances  of  pulmonary  pbthisis,  also 
presents  but  few  cases,  some  of  them  being  doubtful.  However,  all 
these  do  not  belong  to  the  type  of  the  corresponding  ulcer ;  they 
are  rather  true  areas  of  tubercular  softening  as  they  occur  every- 
where with  central  cheesy  degeneration  of  the  tubercle  tissue.  At 
all  events,  there  is  a  combination  with  the  corrosive  action  of  the 
gastric  juice  on  the  necrotic  tissue  elements:}:  [see  page  418]. 

The  syphilitic  ulcer  is  not  marked  by  characteristic  anatomical 
features.  In  the  majority  of  the  few  cases  thoroughly  observed, 
the  question  whether  the  ulcer  was  a  primary  lesion  or  a  broken- 
down  gumma  is  not  broached.*  [The  relations  of  syphihs  and  gastric 
ulcer  are  discussed  in  some  detail  by  Neumann,  ||  who  considers  their 
occurrence  in  this  disease  by  no  means  as  rare  as  has  been  supposed. 
He  believes  that  the  ulcers  which  are  found  in  syphilitic  patients 
may  be  either  true  peptic  ulcers  or  broken-down  gummata  (see 
page  41 Y).] 

Symptoms. — As  is  well  known,  some  gastric  ulcers,  healing  by 
cicatrization,  run  their  course  during  life  without  presenting  any 
symptoms  whatever,  or  only  a  few  which  are  not  at  all  characteristic; 
they  are  then  only  found  accidentally  after  death.  Their  occur- 
rence had  already  been  established  by  Williams,  Abercrombie,  and 
Chambers,  and  naturally  they  do  not  come  under  clinical  observa- 
tion. [A  very  interesting  case  of  latent  ulcer  has  recently  been 
pubhshed  by  Dieulaf oy.^  There  were  absolutely  no  symptoms  until 
perforation  occurred ;  and  yet  there  were  two  ulcers,  one  of  which 

*  Eisenhardt.  Ueber  die  Haufigkeit  dar  Darmtuberkulose.  Inaug.  Dissert., 
Munich,  1891. 

f  Marfan.  Troubles  et  lesions  gastriques  dans  la  phthisie  pulmonaire.  Paris, 
1887. 

J  [Full  bibliography  of  tuberculosis  of  the  stomach  will  be  found  in  W.  S.  Fen- 
wick,  Dyspepsia  of  Phthisis,  London,  1894,  p.  198. — Ed.] 

*  Galliard.  Syphilis  gastrique  et  ulcere  simple  de  I'estomac.  Arch,  gener.  de 
med.,  1886,  pp.  66  et  seq. 

II  [Neumann.  Syphilis.  Nothnagel's  Encyclopaedia,  1896,  Bd.  sxiii,  p. 
354.— Ed.] 

^  [Dieulafoy.  Presse  med.,  July  25,  1896.  Full  abstract  in  New  York  Medical 
Journal,  August  15,  1896,  p.  245.— Ed.] 


SYMPTOMS  OF  GASTRIC   ULCER.  4,13 

was  as  large  as  a  half-dollar.  According  to  Stoll,-  who  has  pub- 
lished statistics  based  upon  3,476  autopsies,  gastric  ulcers  run  a 
latent  course  in  27  per  cent  of  the  cases.] 

The  various  ulcers  of  the  stomach  may  be  arranged,  according 
to  their  symptoms,  into  the  following  groups : 

1.  Cases  in  which  the  symptoms  due  to  irritation  predominate, 
and  which  result  in  hsemorrhagic  erosions,  or  in  corrosion  and  ex- 
posure of  a  larger  or  smaller  portion  of  the  mucous  membrane  with- 
out the  development  of  further  comphcations. 

2.  Cases  with  these  symptoms  of  irritation,  together  with  h^em- 
orrhages. 

3.  Cases  with  symptoms  of  irritation  and  perforation,  resulting 
in  recovery  or  death. 

4.  Cases  which  remain  latent  until  death  occurs  by  haemorrhage 
or  perforation. 

The  fact  that  the  symptoms  of  the  fii'st  three  groups  may  be 
combined  in  various  ways  explains  why  the  chnical  picture  is  so 
changeable  ;  and  if,  in  addition,  the  results  of  cicatrization  are  also 
included,  it  becomes  even  more  comphcated.  The  first  stages  mani- 
fest themselves  by  those  conditions  of  discomfort  which  we  find  at 
the  commencement  of  so  many  diseases  of  the  stomach,  such  as 
vague  sensations  of  pressure,  transient  drawing  pains,  and  the  ac- 
companying disturbances  of  the  appetite.  However,  the  tongue  is 
usually  clean,  or  only  moderately  coated  at  the  base.  On  strict  in- 
quiry we  find  that  the  patients  eat  very  little,  and  usually  keep  a 
fairly  strict  diet,  not  on  account  of  lack  of  appetite,  but  owing  to 
the  dread  of  having  pain  after  a  full  meal.  For  this  gastralgia 
forms  a  marked  feature  of  the  picture,  even  early  in  the  disease. 
The  accompanying  catarrhal  gastritis  is  but  rarely  sufliciently  marked 
to  cause  true  anorexia,  foul  taste,  belching,  bad  odor  from  the 
mouth,  and  heavily  coated  tongue. 

Only  in  the  rare  cases  in  which  a  girdlelike  ulcer  or  a  cicatrix 
interferes  with  the  peristalsis  of  the  stomach  and  causes  dilatation, 
is  there  marked  decomposition  of  the  stomach  contents  and  belch- 
ing of  foul  gases.     Sluggishness  of  the  bowels  is  the  rule ;  diar- 

*  [StoU.    Deutsch.  Arch,  fur  klin.  Med.,  Bd.  lii,  Hefte  5  und  6.— Ed.] 


404  DISEASES  OP  THE  STOMACH. 

rhoea,  or  a  condition  in  whicli  the  two  alternate,  tlie  exception. 
The  intestinal  functions  are  rarely  found  to  be  normal  and  un- 
disturbed. 

Chronic  ulcer  runs  its  course  without  fever,  and,  should  an  in- 
creased temperature  be  present  in  conditions  of  exhaustion  toward 
the  end  of  life,  or  in  certain  forms  of  ulcer  running  an  acute  course, 
they  are  due  to  inflammatory  processes,  such  as  gastritis,  peritonitis, 
or  pneumonic  infiltrations. 

Recent  cases  are  not  usually  accompanied  by  disturbances  of 
nutrition  ;  they  may  even  be  absent  after  the  ulcer  has  existed  for 
some  time.  Most  patients,  however,  eventually  emaciate  on  account 
of  their  scanty  diet  and  frequently  lose  weight  so  rapidly  as  to 
cause  apprehension,  so  that  losses  of  20  kilogrammes  [44  pounds] 
and  more  in  a  few  months  are  not  uncommon.  This  depends  partly 
on  the  previous  condition,  and  occurs  more  frequently  in  the  strong 
and  stout  than  it  does  in  lean  persons. 

Gradually  the  pains  become  localized  to  a  definite  spot  corre- 
sponding to  the  site  of  the  ulcer,  and  as  this  is  commonly  situated  in 
the  lower  half  of  the  stomach,  and  as  the  painful  spot  can  not  be 
localized  with  exactness,  it  is  usual  to  have  it  referred  to  the  infra- 
sternal  depression.  The  boring,  sharply  localized  pain,  frequently 
darting  from  before  backward,  is  characteristic.  Some  patients 
complain  only  of  pain  in  the  back,  others  of  "  stitches  in  the  side," 
owing  to  which  the  disease  may  be  mistaken  for  intercostal  neural- 
gia. [The  pain  in  the  back  is  usually  localized,  especially  on  the 
left  side,  at  the  twelfth  dorsal  and  first  lumbar  vertebrae.  Localized 
tenderness  in  this  area  is  very  frequently  observed.]  As  a  rule, 
pressure  increases  it ;  women  can  not  lace,  and  men  can  not  pull 
the  band  of  their  trousers  tight.  In  rare  cases,  on  the  other  hand, 
pressure  eases  the  pain.  It  appears  in  attacks  most  frequently  on 
mechanical  or  thermal  irritation  of  the  exposed  surface  of  the  ulcer. 
Of  course,  this  is  primarily  and  most  frequently  the  case  after  eat- 
ing, the  food  either  causing  direct  irritation  on  its  introduction,  or 
stretching  the  wall  of  the  stomach  by  its  weight,  or  the  surface  of 
the  ulcer  is  distorted  and  its  nerves  irritated  by  the  contractions 
accompanying  digestion.  But  this  is  not  the  only  cause.  I  have 
repeatedly  seen  severe  gastralgia  in  patients  with  ulcer  of  the  stom- 


SYMPTOMS  OP  GASTRIC  ULCER.  405 

ach,  after  a  drink  which  was  too  cold,  or  a  spoonful  of  soup  or  tea, 
etc.,  which  was  too  hot ;  in  these  cases,  consequently,  the  pain  could 
not  be  attributed  to  the  above-mentioned  factors,  but  onlj  to  ther- 
mal irritation.  Moreover,  according  to  my  experience,  ingesta 
which  are  too  hot  are  less  often  the  cause  than  those  which  are  too 
cold,  perhaps  because  the  mouth  and  throat  act  as  guards  to  the 
stomach  in  the  former  case,  and  because  the  mucous  membrane  of 
the  stomach  is  more  tolerant  of  high  degrees  of  temperature  than  it 
is  of  low,  and  also  because  smaller  quantities  of  the  former  are  taken 
than  of  the  latter.  The  state  of  the  ingesta  is  also  certainly  not 
without  influence  on  the  reaction  of  the  mucous  membrane.  A  re- 
markable example  of  this  is  recorded  by  Dunglison  :  * 

Numerous  cases  of  severe  acute  gastritis  occurred  among  the  workmen 
in  Virginia  who,  becoming  overheated  under  the  hot  sun,  quenched  tlieir 
thirst  with  large  quantities  of  cold  spring  water ;  these  attacks  were  rap- 
idly followed  by  death.  On  substituting  small  pieces  of  ice  instead  of  the 
water,  this  disease  practically  disappeared. 

To  be  sure,  there  are  many  patients  who  never  have  trouble  after 
eating,  but,  instead,  the  attacks  of  gastralgia  appear  when  the  stom- 
ach is  empty,  and  even  in  the  night.  Here  the  cause  may  be  the 
secretion  of  hyperacid  gastric  juice,  which  is  still  to  be  spoken  of. 
On  the  other  hand,  gastralgia  may  be  caused  by  the  distention  of 
the  walls  of  the  stomach  by  gases,  or  by  irritation  of  the  nerve  fibers 
due  to  the  progressing  process  of  ulceration,  while  the  attacks  of 
gastralgia  caused  by  colds  and  excitement,  and  the  increased  pain 
before  the  menstrual  epoch  and  its  cessation  on  the  appearance  of 
the  menses,  may  be  regarded  as  reflex  in  character.  A  peculiar 
symptom  occasionally  seen  is  the  cutaneous  hypersesthesia  and  anses- 
thesia  observed  by  Traube  f  and  referred  by  him  to  a  central  "  irra- 
diation." The  causes  of  the  gastralgias  lead  to  the  fact  that  they 
usually  appear  suddenly  and  with  great  intensity  at  once,  and  as 
rapidly  subside,  so  that  a  nearly  normal  condition  is  very  soon  estab- 
lished ;  paroxysms  which  gradually  increase  in  intensity  are  less 
frequently  observed. 

The  Changes  in  the  Chemical  Functions  of  the  Stomach. — At  all 

*  Quoted  by  Copeland,  Dictionary  of  Pract.  Med ,  article  Indigestion, 
t  Traube.     Deutsche  Kliuik,  1861,  S.  G3. 


406  DISEASES  OF  THE  STOMACH. 

events,  the  appetite  of  patients  witli  gastric  ulcers  and  their  digestive 
power  show  that  they  are  not  lessened.  To  Riegel  and  his  fol- 
lowers* is  due  the  credit  of  having  been  the  first  to  attach  great 
importance  to  occurrence  of  increased  secretion  of  HOI.  I*^umerous 
investigations  f  have  shown  that  this  hyperchlorhydria  is  not  con- 
stant, as  was  at  first  supposed  by  Riegel,  but  it  is  nevertheless  found 
in  the  great  majority  of  cases.  The  statement  long  ago  made  by 
me,:}:  that  "in  cases  of  ulcer  the  gastric  juice  always  contains  HCl, 
and  usually  an  excess  of  it,"  may  to-day  be  generally  accepted. 
Yon  Korczynski  and  Jaworski  *  in  a  few  cases  have  also  observed 
the  untimely  occurrence  (i.  e.,  on  an  empty  stomach)  of  continuous 
acid  hypersecretion  ;  they  have  noticed  that  the  acidity  increased  or 
diminished  in  the  same  degree  as  the  patient's  subjective  symptoms, 
but  it  was  greatest  just  before  the  occurrence  of  a  hsetnorrhage. 
But  all  authorities  agree  that  the  acidity  due  to  HCl  may  reach  90 
to  100,  and  even  as  high  as  108  and  110.  It  is  self-evident  that  the 
hyperacidity  of  the  chyme  will  interfere  with  digestion,  the  diges- 
tion of  proteids  being  more  rapid  and  complete  than  of  the  starches. 
Thus  in  the  stomach  contents  after  a  mixed  meal  one  will  find  that 
all  the  meat  has  been  digested,  while  a  larger  or  smaller  residue  of 
starches  will  be  found  unchanged. 

Changes  in  the  Urine. — Such  a  hyperchlorhydria  is  necessarily 
caused  by  an  abnormally  large  decomposition  of  the  chlorides,  which 
in  turn  causes  a  larger  amount  of  the  corresponding  bases  to  appear 
in  the  urine — i.  e.,  the  urine  becomes  more  alkaline.  This  has  been 
systematically  observed  by  Quincke,  Maly,  Sticker  and  Hiibner,! 
and  Ferrarini.^     Gluczynski  ()  was  the  first  to  call  attention  to  the 

*  F.  Riegel.  Beitrage  zur  Diagnostik  der  JVIagenkrankheilen.  Zeitschrift  fiir 
klin.  Med.,  Bd.  xii,  p.  434,  etc. ;  Volkraann's  Sammlung  klin.  Vortrage,  No.  289 ; 
Deulsch.  med.  Wochenschr.,  1886,  No.  52. — Vogel.  Beitrage  zur  Lehre  vom  Ulcus 
ventriculi  simplex.     Inaug.  Dissert.,  Giesen,  1887,  and  others. 

f  Rothschild.  Inaug.  Dissert..  Strassburg.  1886. — Ewald.  Berl.  klin.  Wochen- 
schr., 1886,  No.  23.— Ritter  und  Hirsch.  Zeitschr.  filr  klin.  Med.,  Bd.  xiii,  p.  446.— 
C.  Gerhardt.  Deutsch.  med.  Wochenschr.,  1888,  No.  18. — Rosenheim.  Ibid.,  No, 
22,  and  others. 

X  Ewald.     First  American  edition  of  this  work,  p.  230. 

*  Log.  cit.    Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  xlvii. 

II  Sticker  und  Hiibner.     Zeitschr.  fiir  klin.  Med.,  Bd.  xii,  p.  114. 

^  Ferrarini.     Riforma  medic,  April  24,  1891, 

0  Gluczynski.     Berl,  klin.  Wochenschr.,  1888,  No.  53. 


SYMPTOMS  OP  GASTRIC   ULCER.  40Y 

complete  absence  of  the  chlorides  from  the  urine,  a  fact  which  can 
be  readily  corroborated ;  hence  a  high  alkahne  reaction  of  the  urine 
and  the  absence  of  chlorides  indicate  marked  changes  in  the  func- 
tional activity  of  the  glands  of  the  stomach.     [See  page  163.] 

Condition  of  the  Blood. — Most  writers,  such  as  Laache,  Leich- 
tenstern,  Eeinert,  and  Ostersprey,*  have  found  changes  in  the  blood 
which  were  independent  of  any  haemorrhages  ;  the  number  of  red 
cells  and  the  percentage  of  hgemoglobin  were  diminished,  while  at 
times  the  number  of  white  cells  was  increased.  The  contradicting 
observations  of  Miiller  and  Oppenheimer,  f  however,  show  that  al- 
though these  results  are  common,  yet  they  are  not  always  found, 
and  hence  have  not  specific  relations  to  gastric  ulcer,  and  therefore 
depend  upon  secondary  conditions,  such  as  chlorosis,  anaemia,  etc. 
Immediately  after  a  heemorrhage  we  find  the  usual  blood  changes 
after  such  occurrences — i.  e.,  a  diminution  of  the  red  cells  and  haemo- 
globin and  a  slight  increase  of  the  leucocytes. 

The  next  symptom  to  be  considered  is  vomiting,  both  of  food 
and  of  blood.  Yomiting  usually  occurs  soon  after  eating.  It  is  due 
to  the  irritation  caused  by  the  food,  and  not  to  an  accumulation  of 
ingesta,  as  is  the  case  in  dilatation  of  the  stomach.  The  food  is 
brought  up  only  slightly  changed  and  mixed  with  some  mucus,  as  in 
the  morning  vomiting  of  drunkards.  Fermentation  fungi  and  other 
foreign  cellular  elements,  with  the  exception  of  the  occasional  ad- 
mixture of  blood,  are  absent,  or  are  (for  example,  sarcinae)  very  rare. 
At  other  times  the  vomit  is  watery,  with  a  light  greenish  tinge, 
very  acid,  and  on  standing  there  is  a  mushy  deposit  which  consists 
chiefly  of  starch  granules,  cellular  detritus,  and  scanty,  well  digested 
fragments  of  meat.  There  may  also  be  periods  in  which  the  vomit 
is  very  copious,  when  the  stomach  is  absolutely  intolerant  toward 
food. 

Hcematemesis. — When  the  blood  comes  from  small  vessels,  the 
quantity  is  usually  small ;  if  recent,  it  appears  only  as  fine  bloody 
streaks  in  the  vomit ;  but  if  the  gastric  juice  has  had  an  opportunity 
to  act  for  a  longer  time  upon  the  blood  while  it  was  accumulating, 
then  it  is  changed  to  reddish-brown,  granular  masses.     Small  quan- 


Ostersprey.     Vide  supra,  p.  337.  f  Miiller.     Vide  supra,  p.  337. 

27 


408  DISEASES  OF  THE  STOMACH. 

titles  of  blood  may  easily  escape  observation  wben  no  vomiting  oc- 
curs and  tlie  blood  is  carried  into  tlie  intestines  ;  here  it  is  altered  to 
such  an  extent  that  nothing  is  noticeable  by  simple  inspection  of  the 
f  geces.  Under  such  circumstances,  as  has  been  shown  by  Schmauss, 
the  blood  in  the  stool  can  only  be  demonstrated  by  a  microscopic, 
spectroscopic,  or  chemical  examination.  However,  the  detection  of 
small  quantities  of  blood  in  the  stools  is  always  a  difficult  task,  be- 
cause the  red  cells  are  usually  so  altered  in  the  intestines  that  they 
lose  their  characteristic  form.  This  difficulty,  which  is  not  encoun- 
tered in  large  bleedings,  is  increased  in  small  haemorrhages,  especially 
if  the  patient  has  taken  preparations  of  mercury  [iron,  bismuth]  and 
sulphur,  which  give  a  dark  color  to  the  fseces.  In  this  way  the 
cause  of  an  obscure  anaemia  may  be  discovered.  In  fact,  this  is 
possible  much  more  frequently  than  is  generally  assumed ;  conse- 
quently repeated  examination  of  the  faeces  should  not  be  omitted 
after  gastralgic  attacks,  or  indeed  in  any  obscure  case  of  gastric  or 
intestinal  diseases. 

Profuse  hagmorrhages  presuppose  the  erosion  of  a  larger  vessel ; 
the  blood  acts  as  an  emetic  on  the  stomach,  so  that  it  empties  itself 
of  its  contents.  Many  patients  have  a  distinct  and  positive  premo- 
nition in  the  form  of  flashes  of  heat,  epigastric  pulsation,  fullness  in 
the  region  of  the  stomach,  and  great  and  apparently  groundless  rest- 
lessness, as  in  the  case  described  at  the  beginning  of  this  chapter. 
The  time  during  which  the  blood  remains  in  the  stomach  varies, 
and  with  this,  consequently,  the  appearance  of  the  vomited  masses. 
In  some  cases  we  find  bright-red  clots,  in  others  dark,  brownish-red 
masses,  while  in  the  great  minority  of  cases  it  presents  the  appear- 
ance of  coffee  grounds.  The  presence  of  blood  in  the  vomit  can,  as 
a  rule,  be  readily  established  with  the  naked  eye  ;  it  can  always  be 
easily  discovered  with  the  microscope  or  spectroscope,  or  by  means 
of  Heller's  blood  test.  We  must  not  forget  that  confusion  may 
arise  if  the  patient  has  partaken  of  red  wine,  cacao,  colored  medi- 
cines, cinnamon,  or  real  coffee  grounds ;  but  a  glance  through  the 
microscope  will  readily  settle  this  question.  Part  of  the  blood 
passes  into  the  intestines.  This  is  the  rule  in  the  smaller  haemor- 
rhages which  do  not  lead  to  vomiting  ;  the  blood  mingles  with  the 
rest  of  the  intestinal  contents  and  is  not  recognizable  in  the  faeces, 


SYMPTOMS  OF  GASTRIC   ULCER.  409 

or  is  overlooked.  In  the  case  of  larger  hsemorrliages,  or  if  the  ulcer 
is  situated  in  the  duodenum,  the  evacuations  consist  of  tarry,  very 
offensive  masses. 

The  estimation  that  hsematemesis  occurs  in  50  per  cent  of  the 
cases  is  rather  too  high  than  too  low.  Brinton  gives  29  per  cent ; 
"Witte,  of  Copenhagen,  found  it  100  times  in  339  cases ;  and  Ger- 
hardt  saw  it  in  47  per  cent  of  his  cases ;  so  we  may  assume  that 
considerably  more  than  half  the  patients  do  not  have  hsematemesis. 

In  an  interesting  study  of  the  records  of  Guy's  Hospital  from 
1870  to  1890,  Hood  *  has  shown  that  the  majority  of  cases  of  ulcers 
which  occurred  under  the  thirtieth  year  were  women,  and  that  death 
was  extremely  rare  at  this  youthful  period  of  life.  Of  66  such  cases, 
29  were  under  thirty  years  old,  of  whom  only  2  were  men  ;  whereas 
11  of  the  21  cases  which  occurred  between  the  thirtieth  and  fortieth 
years  were  men.  All  cases  recovered.  Seven  other  cases  which 
were  fatal  immediately  after  haemorrhage  were  all  over  thirty  years 
old;  4  of  them  were  women,  aged  thirty -three,  thirty-five,  fifty,  and 
fifty-three  years.  Although  we  must  not  infer  that  the  prognosis 
of  hsematemesis  suddenly  changes  with  the  thirtieth  birthday,  yet 
these  statistics  indicate  that  the  prognosis  of  hsematemesis  in  youth- 
ful women  is  not  bad ;  on  the  contrary,  after  such  catastrophes  we 
often  see  a  remarkable  improvement,  lessening  of  the  distressing 
symptoms,  and  improvement  of  the  blood.  Thus  in  one  of  my  cases 
within  three  weeks  after  hsematemesis,  the  number  of  red  blood- 
cells  were  from  1,900,000  to  3,040,000  and  4,070,000,  and  the  per- 
centage of  hsemoglobin  from  31  to  51.  I  have  also  repeatedly  seen 
similar  occurrences. 

The  bloody  masses  after  hsemorrhage  from  ulcer  contain  no 
specific  elements ;  and  the  red  blood-cells  are  so  abundant  that  the 
cellular  structure  of  the  gastric  mucous  membrane  is  scarcely  or 
not  at  all  to  be  seen. 

When  larger  hemorrhages  have  occurred,  the  danger  of  their 
recurrence  hangs  over  the  patient's  head  like  the  sword  of  Damo- 
cles, and  in  a  twofold  manner :  First  of  all,  repeated  hsemorrhages 
occur  in  the  course  of  the  day,  even  several  times  during  the  same 

*  W.  Charles  Hood.     Hsematemesis,  with  Special  Reference  to  that  Form  met 
with  in  Early  Female  Life.     London,  J.  Bale  &  Sons,  1892. 


410  DISEASES  OF  THE  STOMACH. 

day,  or  at  short  intervals,  say,  during  a  week.  Then  we  must . 
assume  that  there  are  recurrences  from  the  same  vessel  which 
was  lirst  opened.  Secondly,  after  a  pause  of  months,  or  even  years, 
fresh  hsematemesis  appears.  Its  return  may  be  due  to  a  tendency 
of  ■  the  individual  to  this  kind  of  haemorrhage.  In  order  to  form 
any  idea  at  all  why  in  certain  persons  extensive  ulcers,  which  must 
necessarily  have  involved  large  vessels  in  their  growth,  run  their 
course  without  haemorrhage,  and  others  are  marked  by  such  profuse 
haemorrhage,  we  must,  in  my  opinion,  assume  a  certain  predispo- 
sition to  a  deficiency  in  the  fibrinoplastic  power  of  the  blood,  and 
with  this  an  insufficient  or  ineffectual  formation  of  thrombi.  It  oc- 
casionally appears,  too,  as  if  the  thrombi  after  being  formed  were 
very  loosely  attached  and  could  be  quite  easily  displaced,  as  soon 
as  the  heart's  action  exceeded  its  normal  strength.  Thus  I  have 
twice  seen  a  haemorrhage  recur  after  a  long  period  of  quiescence, 
caused  by  the  patients,  who,  thinking  themselves  well,  had  in- 
dulged in  strong  alcohohc  beverages,  although  only  in  small  quan- 
tities. 

Small  haemorrhages  have  no  influence  on  the  condition  of  the 
patient,  except  psychically ;  larger  haemorrhages,  especially  if  recur- 
ring at  short  intervals,  lead  to  a  high  degree  of  anaemia  and  its 
consequences.  Waxy  pallor  of  the  skin,  small,  rapid  pulse,  slight 
febrile  movements,  complete  anorexia,  ringing  in  the  ears  and  ver- 
tigo, transient  mild  delirium,  and  even  complete  loss  of  conscious- 
ness, may  occur.  Subsultus  tendinum  and  convulsions  in  the  ex- 
tremities have  even  been  observed.  In  spite  of  this,  as  a  rule,  the 
patients  rally  comparatively  rapidly,  and  under  appropriate  treat- 
ment soon  tend  to  regain  their  lost  powers.  We  may  also  observe 
oedema  of  the  lower  extremities,  especially  at  night,  after  the  patient 
has  been  on  his  legs  all  day,  and  also  amaurosis,  which  may  occur 
soon,  or  some  time  after  the  bleeding.  According  to  Fries,^  amau- 
rosis occurs  in  65*5  per  cent  of  all  cases  of  bleeding  from  the  in- 
testinal tract ;  but  its  real  relation  to  haematemesis  has  by  no  means 
yet  been  made  clear. 

Immediately  fatal  cases  of  gastric  haemorrhage  from  the  vessels 

,  *  S.  Fries.    Beitrage  zur  kenntniss  der  Amblyopie  und  Amaurose  nach  Blutver- 
lusten.    Inaug.  Dissert,,  Tubingen,  1876. 


SYMPTOMS  OF  GASTRIC   ULCER.  411 

of  the  stomach,  esi^eciallj  in  youthful  persons,  as  has  been  shown 
above,  are  comparatively  rare.  In  most  the  cause  has  been  perfora- 
tion of  the  ulcer  (see  page  406),  and  the  involvement  of  the  splenic 
or  pancreatic  artery,  the  portal  vein  or  the  left  heart.  Cruveilhier 
pictures  a  case  in  which  the  stomach  was  distended  with  fluid, 
brownish-red  blood.  Budd  saw  a  case  in  which  not  only  the 
stomach  but  also  the  entire  intestinal  tract  was  full  of  blood,  and  in 
which  the  patient  had  bled  to  death  into  his  o^vn  body.  A  case 
reported  by  Finny  is  interesting :  * 

A  young  man,  nineteen  years  of  age,  in  whom  phthisis  had  been  sus- 
pected, and  who  for  some  time  had  had  hectic  fever,  died  suddenly.  There 
were  no  symj^toms  of  stomach  trouble.  Vomiting  did  not  occur,  not 
even  immediately  before  death.  The  stomach  and  intestines  down  to  the 
anus  were  found  full  of  fluid  blood.  The  stomach,  diaphragm,  pericar- 
dium, and  myocardium  had  all  become  adherent  to  one  another.  A  small 
cannular  comnaunication  led  into  the  left  ventricle  ;  otherwise  its  muscle 
was  normal,  and  was  found  to  have  imdergone  granular  degeneration 
only  in  the  neighborhood  of  the  perforation.  The  ulcer  in  the  stomach 
was  situated  on  the  anterior  wall,  and  measured  one  inch  and  a  quarter 
in  length  by  three  quarters  of  an  inch  in  width. 

A  small  aneurism  of  the  gastric  artery  was  the  cause  of  death  in 
a  case  reported  by  Powell. f  The  ulcer  was  situated  near  the  cardia 
on  the  lesser  curvature,  and  in  the  center  was  a  ruptured  aneurism 
of  the  size  of  a  pea,  the  profuse  haemorrhage  from  which  caused  the 
death  of  the  patient  in  a  few  minutes. 

Referring  to  the  fourth  group  mentioned  above  [page  39-i],  we 
see  that  haemorrhages  may  occur  without  any  previous  indication  of 
a  gastric  ulcer,  and  in  fact  these  have  frequently  been  observed.  I 
wish  to  again  recall  to  your  memory  the  case  described  at  the  com- 
mencement of  the  chapter  as  belonging  in  this  category.  However, 
in  this  patient  vague  symptoms  of  a  grave  illness  preceded  the  fatal 
hjemorrhage,  while  in  other  cases  it  has  killed  apparently  healthy 
persons  with  alarming  and  unexpected  suddenness.  In  this  connec- 
tion a  case  of  haemorrhage  from  the  intestines  described  by  Pois- 
son :}:  is  of  diagnostic  interest ;  the  bleeding  appeared  during  conva- 

*  Finny.  Ulcer  of  the  Stomach  opening  in  the  Left  Ventricle  of  the  Heart. 
Brit.  Med.  Jour.,  1886,  i,  p.  1102. 

f  Powell,     Transact.  Pathol.  Soc.  [London],  vol.  xxix,  p.  133. 
X  Poisson.    Bull,  de  la  Soc.  anat.  de  Paris,  Febr.,  1855. 


4:12  DISEx^SES   OF  THE  STOMACH. 

lescence  from  an  attack  of  typhoid,  and  might  have  occasioned  its 
being  mistaken  for  a  typhoid  haemorrhage. 

Hollevoet  *  describes  a  case  of  ulcer  with  hsemorrhage  which 
was  followed  by  marked  purpura  hgemorrhagica.  But,  as  in  this 
case  (which  recovered),  there  were  also  renal  haemorrhages.  Scurvy 
may  also  have  been  present. 

A  severe  complication  of  this  disease  is  produced  by  the  perfo- 
ration of  the  ulcer  and  the  involvement  of  the  neighboring  organs. 
When  the  digestive  process  has  reached  the  serous  layer  of  the 
gastric  wall,  and  has  involved  one  of  the  neighboring  organs 
(among  which  I  here  include  the  coils  of  intestine),  it  manifests  itself 
occasionally  by  a  localized  sensation  of  pain,  referable  to  the  posi- 
tion of  the  affected  viscus.  Most  frequently,  however,  it  runs  its 
course  without  any  outward  manifestation,  so  that  only  when  dis- 
turbances of  function  appear  in  the  organs  involved  do  we  recog- 
nize the  fact  that  they  are  similarly  aifected.  Or  haemorrhages 
may  occur  from  the  larger  vascular  trunks,  especially  in  the  pan- 
creas and  spleen,  which  are  naturally  in  no  way  to  be  distinguished 
from  those  already  considered. 

I  do  not  consider  it  essential  to  give  a  detailed  account  of  the 
intercurrent  affections  possible  here,  and  which  I  have  already  re- 
ferred to  above,  although  the  literature  of  the  past  fifty  years  is  full 
of  reports  of  all  such  complications.  "We  can  readily  conceive  of 
the  occurrences  in  question  on  calling  to  mind  the  topography  of 
the  stomach  and  its  relations  to  the  surrounding  organs.  The  most 
interesting  is  the  perforation  through  the  diaphragm  f  [sometimes 
giving  rise  to  diaphragmatic  hernia]  and  pericardium  into  the  left 
heart,:}:  with  pneumo-pericarditis,  or  into  the  mediastinum,  with 
cutaneous  emphysema  and  collection  of  inflammable  gases.  West* 
describes  a  case  in  which  the  ulcer  extended  to  the  portal  vein  and 

*  Hollevoet.     Arch.  med.  Beiges,  1892,  No.  3. 

f  [Pick  has  recently  reported  a  case  of  this  kind ;  the  true  condition  was  only 
foimd  at  the  autopsy.  Zeitschrift  fiir  klin.  Med..  Bd.  xxvi.  Bibliography  of  27  cases 
is  given. — Ed.J 

X  [Oser  has  described  a  case  in  which,  although  the  left  ventricle  was  eroded, 
the  patient  survived  two  days.  The  opening  was  closed  during  the  systole  and 
only  open  during  the  diastole ;  the  patient  thus  gradually  bled  to  death.  Addi- 
tional cases  are  quoted  by  Welch  (Pepper's  System  of  Med.,  vol.  ii,  p.  508). — Ed.] 

*  S.  West.     Trans.  Patholog.  Soc,  London,  1890,  p.  147. 


SYMPTOMS  OF  GASTRIC   ULCER.  4I3 

caused  death  from  pylephlebitis.  Those  cases  in  which  encapsulated 
abscesses  containing  air  have  formed  beneath  the  diaphragm  have 
been  described  under  the  name  of  pyopneumothorax  subphrenicus. 
[Subphrenic  abscess  is  by  no  means  rare  after  perforation  of  gastric 
ulcers.  Much  has  recently  been  written  on  this  subject,  especially  by 
Maydl,*  Meltzer,t  Weir,;];  Beck,*  Foote,  ||  and  others.  In  110  cases 
of  subphrenic  abscess  collected  by  Meltzer,  32  occurred  after  gastric 
ulcers  and  9  after  duodenal  ulcers.  The  abscesses  frequently  con- 
tain gas,  and  are  by  no  means  easily  recognized.  Pyopneumothorax 
will  also  exist  if  the  diaphragm  has  been  perforated.  The  diagnosis 
may  be  made  by  the  history  of  the  case,  the  absence  of  Litten's 
"  diaphragm  phenomenon  "  before  perforation  of  the  diaphragm  has 
occurred,  the  presence  of  dullness  over  the  lower  thorax,  not  due  to 
the  liver  or  spleen,  and  the  use  of  the  aspirating  needle  (Weir  and 
Foote).  The  prognosis  is  very  bad  unless  the  condition  is  relieved 
by  operation.]  Perforation  into  the  pleura  -^  can  be  diagnosticated 
if  it  causes  pneumothorax  and  empyema,  or  if  it  leads  to  direct 
communication  with  the  lungs,  and  the  coughing  up  of  particles  of 
food,  which  not  only  may  occur,  but  actually  has  been  reported. 

I  have  already  spoken  of  perforation  into  the  colon  and  the  re- 
sulting lienteric  diarrhoea,  in  discussing  perforation  due  to  cancer- 
ous ulceration.  Perforation  into  the  abdominal  cavity  may  occur  in 
different  ways.  In  fortunate  cases  there  is  a  preceding  adhesive  in- 
flammation between  the  stomach  and  the  neighboring  intestinal  wall 
and  omentum,  thus  forming  a  cavity  representing  a  sac  inclosed  in 
a  sac,  which  prevents  the  escape  of  the  gastric  contents  into  the 
abdominal  cavity.  Then  signs  of  irritation  of  the  peritonaeum 
appear ;  circumscribed  pain  and  distention  of  the  upper  part  of  the 
abdomen,  together  with  fever,  and  sometimes  frequent  vomiting. 
If  the  adhesions  are  more  extensive  they  may  result — as  in  the  case 
of  Budd,  which  I  have  already  mentioned — in  complete  interference 

*  [Maydl.     Der  Subphrenische  Abscess.     Vienna,  1894.— Ed.] 
t  [Meltzer.     N.  Y.  Med.  Journal.  June  24.  1893.— Ed.] 

X  [Weir.     Internat.  Jled.  Magazine,  February.  1892.— Ed.] 

*  [Beck.     N.  Y.  Med.  Record,  1896,  vol.  i,  p.  217.— Ed.] 
n  [^Veir  and  Foote.     Med.  News,  May  2,  1896.— Ed.] 

■^  [In  a  case  reported  by  Muiler,  lutnbricoid  worms  were  found  in  the  pleural 
cavity.     Memorabilien,  xvii,  October,  1872.     Quoted  by  Welch,  loc.  cit. — Ed.] 


414  DISEASES  OF  THE  STOMACH. 

with  the  functions  of  the  intestine,  thus  leading  to  permanent  ob* 
struction,  progressive  marasmus,  and  death. 

Perforation  into  the  peritoneal  cavity  is,  however,  bj  far  the 
most  frequent,  either  with  or  without  previous  adhesions  and  for- 
mation of  abscess.  It  may  follow  slowly  and  gradually,  or,  rather, 
the  escape  of  the  gastric  contents  may  be  slow.  In  such  cases  sac- 
culated abscesses  may  form,  which  remain  encapsulated,  or  burst 
later  on  and  cause  general  peritonitis.  As  a  rule,  though,  the  per- 
foration occurs  quite  suddenly,  mthout  any  warning  or  symptoms 
referable  to  it.  The  patients  suddenly  experience  severe  pain  in 
the  abdomen,  causing  them  to  collapse  to  a  certain  extent.  This 
appears  without  cause,  or  after  a  preceding  traumatism,  such  as  an 
accidental  blow,  or  after  leaning  on  the  edge  of  a  table  or  window- 
sill,  after  riding,  after  a  hearty  meal,  or  after  vomiting.  In  a  short 
time  the  clinical  picture  of  peritonitis  due  to  jDerf oration  is  devel- 
oped :  distention  of  the  abdomen,  severe  pain  even  on  the  slightest 
touch,  vomiting,*  singultus,  facies  HijDpocratica,  small  pulse,  and 
finally  death.  Yet,  as  in  the  case  recorded  at  the  commencement  of 
this  chapter,  the  perforation  may  occur  without  the  appearance  of 
any  of  these  signs.  Inasmuch  as  the  patient  had  practically  taken 
no  food  for  three  days  previously,  the  stomach  in  this  case  was 
empty  both  of  food  and  gas,  and  consequently  the  perforation  of 
the  ulcer  was  accompanied  only  by  the  symptoms  of  profound  shock 
— ^unconsciousness,  Cheyne-Stokes  respiration,  extremely  small  pulse, 
cold  skin,  etc. — while  the  abdomen  was  neither  markedly  distended 
nor  very  painful. f 

Such  perforations  may  also  be  caused  by  convulsive  contractions 
of  the  stomach  after  vomiting,  induced  either  by  drugs  or  by  the 
introduction  of  the  finger  into  the  throat,  as  many  patients  are 
fond  of  doing  in  order  to  produce  vomiting  or  belching,  or  after 


*  [Some  uncertainty  exists  as  to  the  existence  of  vomiting  in  perforation.  Struve 
found  it  in  two  thirds  of  his  cases,  and  says  that  it  is  liable  to  be  absent  in  large 
perforations.  Weir  and  Foote  found  it  in  36  per  cent  of  their  cases,  in  8  per 
cent  it  was  absent ;  in  the  remainder  (56  per  cent)  no  reference  is  made  to  this 
symptom.  "  Certainly  the  presence  of  vomiting  in  no  wise  argues  against  the  diag- 
nosis of  perforation  of  the  stomach."  Weir  and  Foote.  Med.  News,  April  25, 
1896,  p.  461.— Ed.] 

f  Even  unconscious  individuals  react  still  to  severe  painful  sensations. 


SYMPTOMS  OF  GASTRIC  ULCER.  415 

tlie  introduction  of  the  stomach  tube.  Faber  *  describes  a  case  of 
perforation  after  vomiting  brought  on  by  the  patient.  According 
to  Bouilleaud,f  the  normal  act  of  defecation  may  give  rise  to  per- 
foration. 

In  the  practice  of  one  of  my  colleagues  I  have  myself  recently  observed 
a  case  of  perforation  of  an  ulcer  which  had  caused  stenosis  of  the  pylorus  ; 
the  opening-  was  the  size  of  a  cherry  pit.  This  occurred  during  the  even- 
ing, after  lavage  of  the  stomach,  which  had  at  one  time  been  recommended 
by  me  on  account  of  the  marked  dilatation  of  the  stomach  and  accumula- 
tion of  its  contents.  Immediately  afterward  the  emaciated  and  miserable 
patient  complained  of  severe  abdominal  pain  and  distention,  and  died  in 
collapse  that  very  night.  At  the  autopsy,  air  and  blackish-brown  stomach 
contents  were  found  in  the  abdominal  cavity.  The  stomach  was  enor- 
mously dilated,  and  the  jjylorus  so  narrow  that  a  pencil  could  scarcely  be 
passed  through  it.  Just  above  this  was  an  ulcer.  It  was  about  the  size 
of  a  2-mark  [.50-cent]  piece,  with  wall-like  and  thickened  (carcinomatous  ?) 
edges,  and  in  the  center  was  a  circular  perforation  with  very  smooth,  sharp 
contour,  not  at  all  ragged  or  torn,  and  in  no  way  suggesting  a  recent  wound. 
Inasmuch  as  my  colleague  used  a  soft-rubber  tube,  taking  all  necessary 
precautions,  a  direct  lesion  caused  by  it  may  be  excluded.  My  explana- 
tion of  the  case  is  rather  that  a  slight  adhesion  had  taken  place  and  was 
broken  up  by  the  marked  traction  on  the  gastric  or  abdominal  walls 
which  always  accompanies  the  washing  out  of  the  stomach. 

I  have  had  a  similar  experience  in  the  case  of  a  young  woman,  twenty- 
one  years  old,  with  an  ulcer  about  the  size  of  the  palm  of  the  hand,  which 
had  undergone  carcinomatous  degeneration.  There  was  a  perforation 
about  as  large  as  a  20-pfennig  [5-cent  nickel]  piece  on  the  lesser  curvature, 
below  the  left  lobe  of  the  liver ;  the  edges  of  the  perforation  were  smooth, 
and  there  was  no  trace  of  recent  inflammation  in  its  vicinity.  During 
the  last  weeks  of  her  life  she  had  vomited  frequently,  but  the  tube  had 
never  been  introduced. 

Cases  which  recover  from  such  perforations  are  exceedingly  rare, 
[Such  a  case  has  been  published  by  Hall.:}:  The  writer. found  only 
six  reported  cases  of  recovery  after  peritonitis  from  perforating  gas- 
tric ulcer.  Three  recovered  completely ;  three  died  in  the  course 
of  subsequent  attacks  ;  autopsies  verified  the  diagnoses.  The  treat- 
ment was  expectant — i.  e.,  opium  and  rectal  alimentation.  The 
good  result  was  attributed  to  the  fact  that  the  perforation  occurred 

*  Faber.  Emphysem  des  Mediastinums  und  der  ausseren  Haut  in  Folge  einer 
Perforation  eines  Magengesehwiirs.  Wiirttemb.  med.  Correspondenzblatt,  1885, 
No.  40. 

f  Bouilleaud.    Arch,  de  med.,  i,  p.  534. 

X  [Hall.  Case  of  Perforating  Gastric  Ulcer,  Peritonitis,  Recovery.  Brit.  Med« 
Jour.,  January  9,  1893.— Ed.] 


416  DISEASES  OF  THE  STOMACH. 

four  hours  after  eating,  when  the  stomach  was  empty.  Pariser  * 
reports  15  authentic  cases  of  recovery  after  acute  perforation,  with- 
out operation.  He,  too,  insists  that  recovery  in  all  these  cases  de- 
pended on  the  empty  condition  of  the  stomach  at  the  time  of  per- 
foration.] "We  really  can  not  speak  of  recovery  in  the  true  sense  of 
the  word,  for  the  adhesions  of  the  intestines,  which  are  produced  in 
the  most  favorable  cases,  lead  to  chronic  illness,  and  death  occurs 
in  a  comparatively  short  time  from  progressive  disturbance  of  nu- 
trition. Sudden  perforations  have  repeatedly  caused  suspicion  of 
poisoning,  and  have  led  to  erroneous  accusations. 

["  G-astrocutaneous  iistulse  are  a  rare  result  of  the  perforation 
of  gastric  ulcer.  The  external  opening  is  most  frequently  in  the 
umbihcal  region,  but  it  may  be  in  the  epigastric  or  in  the  left  hypo- 
chondriac region  or  between  the  ribs."  "Of  the  26  cases  of 
gastrocutaneous  iistulse  collected  by  Murchison,t  18  were  the  result 
of  disease.  In  12  of  these  cases  the  probable  cause  was  simple  gas- 
tric ulcer.  Middeldorpf :{:  says  that  among  the  internal  causes  of  the 
47  cases  of  external  gastric  fistulse  which  he  tabulated,  simple  ulcer 
of  the  stomach  played  an  important  role."] 

The  form  of  the  cicatrization  is  of  great  im,portance.  It  is  very 
apparent  that  cicatricial  contraction  may  lead  to  the  severest  dis- 
turbances of  the  functions  of  the  stomach,  of  which  one — dilatation 
following  cicatricial  stenosis  of  the  pylorus — has  already  been  dis- 
cussed. In  these  cases  a  well-marked  and  characteristic  clinical  pic- 
ture is  developed.  In  other  cases  the  cicatricial  contraction  leads 
to  traction  on  the  nerves  in  the  gastric  wall,  to  deformities  of  the 
viseus,  to  the  shutting  out  of  larger  portions  of  the  muscular  coat, 
or  to  adhesions  with  the  neighboring  organs ;  the  result  is  gastral- 
gias,  or  disturbances  of  function,  which  manifest  themselves  as 
"dyspepsias"  of  various  kinds.  As  a  rule,  the  primary  cause  of 
these  "  dyspepsias  "  is  very  difficult  to  discover ;  a  cure  is  usually  or 
nearly  always  impossible.  I  have  learned  to  fear  these  cicatrices 
even  more  than   the  original  ulcer.     It  is  not  uncommon  for  such 

*  [Pariser.     Deutsch.  med.  Wochenschr.,  1895,  p.  468.— Ed.] 
t  [Miirchison.     Med.-Chir.  Transact.,  London,  1858,  toI.  xli.  p.  11. — Ed.] 
X  [Middeldorpf.     Wiener  med.  Wochenschr.,  1860. — Welch,  loc.  cit.,  vol.  ii,  p. 
508.— Ed.] 


RELATIONS   OF  SYPHILIS  AND  GASTRIC   ULCER.  417 

patients  to  Le  regarded  as  "  nervous  dyspeptics."  If  the  cicatrix  is 
circular  and  at  about  the  middle  of  the  stomach,  forming  the  hour- 
glass stomach,  or  large  saccular  dilatations  may  be  formed,  then 
it  may  happen  that  if  for  some  reason  lavage  is  performed  later  on, 
the  remarkable  phenomenon  may  appear  that  the  stomach  apparently 
can  not  be  emptied.  The  water,  to  be  sure,  comes  away  almost 
clear  after  a  time,  but  it  suddenly  becomes  turbid  again ;  this  may 
be  repeated  many  times.*  In  such  cases  we  either  have  the  condi- 
tion described,  or  an  insufficiency  of  the  pylorus,  permitting  regur- 
gitation of  the  contents  of  the  duodenum  into  the  stomach. 

Syphilis  and  Ulcer. — As  early  as  1838  Andral  inquired  why 
syphilitic  manifestations  could  not  break  out  on  the  mucous  mem- 
brane of  the  stomach  as  well  as  on  that  of  the  mouth.  Since  that 
time  the  question  has  been  frequently  discussed,  and  a  number  of 
more  or  less  convincing  observations  have  been  published  by  Gold- 
stein, Hiller,  Yirchow,  Leudet,  Lanceraux,  Fauvel,  Klebs,  and 
Cornil.  Only  two  cases  of  the  simultaneous  appearance  of  gumma 
and  ulcer  have  been  observed.  Other  observers  (Frerichs,  Drozda, 
Murchison,  Chvostek)  found  scars  in  the  stomach  coincidently  with 
general  syphilis.  Among  100  cases  of  ulcer,  Engel  found  previous 
syphilis  in  10  per  cent,  Lang  f  found  it  in  20  per  cent,  while  Julien:}: 
justly  expresses  himself  with  great  reserve  on  this  subject.  It  must 
always  remain  questionable  in  two  diseases,  as  common  as  those 
under  discussion,  whether  we  are  dealing  with  cause  and  effect  or 
with  an  accidental  coincidence,  especially  since  we  are  by  no  means 
able  in  every  case  to  avoid  confounding  it  with  ulcerating  gumma. 
Here  the  result  of  specific  treatment  can  alone  be  conclusive,  A 
number  of  such  cases  has  been  reported,  for  instance  by  Hiller* 
and  by  Galliard,!  although  the  latter,  who  has  published  the  latest 
monograph  on  the  subject,  admits  that  they  can  not  be  positively 
proved.  At  any  rate,  syphilitic  ulcers  do  not  show  specific  symp- 
toms.    ISTevertheless,  it   is    advisable  to    use    specific  treatment  in 

*  G.  Scherf    (Beitriige    zur  Lehre  von  der  Magendilatation ;    Inaug.  Dissert., 
Gottingen,  1879)  also  observed  this. 

f  [Lang.     Wiener  med.  Presse,  1885.  No.  11. — Ed.] 

t  Julien.     Traite  des  maladies  venoriennes.     Paris,  1886,  p.  880. 

*  Hiller.     Monatschr.  f.  prakt.  Heilkunde,  1883. 
U  Galliard,  loc.  cit. 


418  DISEASES  OF  THE  STOMACH. 

cases  showing  the  signs  of  gastric  nicer  together  with  the  existence 
of  syphihs  [see  page  402]. 

Tuberculosis  and  Ulcer. — As  is  wel  Iknown,  tubercular  ulcerations 
of  the  intestinal  canal  are  common,  but  they  do  not  occur  very  fre- 
quently with  ulcer  of  the  stomach  ;  this  may  be  because  the  germi- 
cidal action  of  the  gastric  juice  prevents  the  proliferation  of  the 
bacilli  which  may  be  introduced  in  swallowed  sputum,  or  in  the 
blood.  [Fenwick*  believes  that  the  rarity  of  tubercular  disease  in 
the  stomach  is  also  due  to  the  small  amount  of  lymphoid  tissue 
which  is  deeply  situated  in  the  mucous  membrane.]  Tubercular 
ulcers  of  the  stomach  present  no  specific  symptoms.  Sudden  death 
from  hsematemesis  due  to  the  involvement  of  vessels  has  also  been 
observed  in  these  cases.  [Musserf  claims  that  this  is  the  rule. 
Fenwick :]:  says  complete  perforation  is  very  rare,  on  account  of 
the  numerous  adhesions  which  are  formed  about  the  base  of  the 
ulcer.  He  could  find  only  one  case  reported,  and  this  he  considers 
doubtful.] 

Diagnosis. — "When  all  the  classical  symptoms  are  present  the 
diagnosis  of  chronic  gastric  ulcer  is  easy  and  scarcely  to  be  mis- 
taken ;  while  if  this  be  not  the  case  it  can  only  be  made  approxi- 
mately, or  not  at  all.  Where  it  deviates  from  its  typical  course 
there  are  practically  two  other  diseases  of  the  stomach,  the  symp- 
toms of  which  resemble  those  of  gastric  ulcer — i.  e.,  gastralgia  or 
gastrodynia,  occurring  as  the  expression  of  nervous  disturbance,  and 
carcinoma.  A  good  survey  of  the  symptoms  of  the  diseases  in 
question  may  be  obtained  by  arranging  them  in  parallel  columns,  as 
Walshe  has  done  in  his  celebrated  treatise  on  cancer.* 


Nervous  Gastealgia. 


Tongue  variable,  often 
pale,  with  indented 
edges. 


Frequent     belching     of 
odorless  eras. 


Gastric  Ulcer. 


Tongue  dry  and  red,  with 
a  white  stripe  down  the 
middle ;  or  smooth  and 
moist,  or  lightly  coated. 

Belching  rare;  or  sour  re- 
gurgitation with  heart- 
burn. 


Gastric  Cancer. 


Tongue  pale  and  furred. 


Frequent  fetid  belching. 


*  [Fenwick,  op.  cit.,  p.  14— Ed.]      f  [Loc.  cit.'\     %  [Fenwick,  op.  cit,  p.  163.— Ed.] 

*  [The  Nature  and  Treatment  of  Cancer.     London,  1846,  p.  389.] 


DIAGNOSIS   OF   GASTRIC   ULCER. 


419 


Nervous  Gastralgia. 


No  change  of  the  taste  in 
the  mouth.  Frequent 
dryness  in  the  mouth  ; 
may  have  salivation. 

Appetite  irregular  and 
capricious. 


Variable  sensations  in  the 
stomach,  at  times  hot 
and  at  others  cold. 


Pain  entirely  iiTegular 
and  not  dependent  up- 
on eating ;  frequently 
eased  by  this  or  by 
pressure  on  the  stom- 
ach. Puncta  dolorosa, 
over  the  intestinal 
plexus. 

Chemistry  of  digestion 
not  essentially  altered. 


Epigastric  pulsation. 


yowiVin^f  variable :  some- 
times only  mucus, 
sometimes  more  or  less 
digested  stomach  con- 
tents ;  seldom  with 
bile. 


No  hcematemesis,  except- 
ing in  unusual  acci- 
dental complications. 


Gastric  Ulcer. 


Obstinate  const ipatioiial- 
ways  present  to  a  great- 
er or  lesser  degree.  Nor- 
mal stool  very  rare.  At 
times  watery,  mucous 
evacuations,  the  so- 
called  pseudo-diarrhoea 


Taste  unchanged. 


Appetite  good  between  the 
attacks.     Thirst. 


Burning  in  the  stomach. 
Circumscribed  boring 
pains,  frequently  radiat- 
ing.to  the  back. 

Pains  rare  when  the  stom- 
ach is  empty ;  chiefly 
after  eating,  or  after 
movements  or  positions 
which  cause  traction  on 
the  stomach.  Increased 
by  pressure. 


Digestion  of  starch  foods 
frequently  retarded.  Di- 
gestion of  meat  normal  or 
even  too  rapid.  Hyper- 
acidity the  rule. 


Vomiting  usually  immedi- 
ately or  within  a  short 
time  after  eating ;  fre- 
quently the  first  symp- 
tom of  the  disease.  Very 
rarely,  hyperacid  vomit- 
ing from  an  empty  stom- 
ach. 


Vomiting  of  clear  blood  or 
cofEee-ground  masses.  As 
a  rule,  frequently  repeat- 
ed within  a  short  time. 
At  times  very  profuse, 
with  intense  anaemia  and 
collapse.  Comparatively 
rapid  recovery.  Bloody 
stools. 

Stool  variable.  Diarrhoea 
due  to  intestinal  irrita- 
tion not  uncommon.  Li- 
enteric  diarrhoea  after 
perforation  into  the  colon. 


Gastric  Cancer. 


Pasty,  insipid  taste. 


Appetite  diminished  or  en- 
tirely absent.  Repug- 
nance to  meat  shown 
early  in  the  disease. 

Feeling  of  oppression,  draw- 
ing, and  pain  of  variable 
character.  Later,  pain  in 
the  shoulder. 

Continuous  dull  pain,  at 
times  becoming  paroxys- 
mal. Frequently  produced 
or  increased  by  pressure. 


Digestion  insufficient ;  as  a 
rule,  deficiency  of  free 
hydrochloric  acid.  For- 
mation of  organic  prod- 
ucts of  decomposition. 

Epigastric  pulsation  oulj 
seen  with  marked  emacia- 
tion. 

Violent  and  frequent  vom- 
iting, often  periodic,  at 
times  from  an  empty 
stomach.  Mucous ;  if  acid, 
it  is  owing  to  organic 
acids.  Always  appears 
first  in  the  course  of  other 
dyspeptic  troubles.  Con- 
sists of  slightly  digested 
food  and  occasionally  can- 
cer cells. 

Blood  more  often  decom- 
posed than  recent.  Quan- 
tity usually  small.  When 
once  commenced,  fre- 
quently recurs  and  with- 
out specially  long  inter- 
vals. 


Obstinate  constipation  al- 
most constant.  Lienterie 
diarrhoea  after  perforation 
into  the  colon. 


420 


DISEASES  OF  THE  STOMACH. 


Nervous  Gastralgia. 


No  fever. 


Complexion  pale,  rarely, 
fresh.  Cutaneous  cir- 
culation normal. 


Occurs  at  all  ages.  Com- 
moner in  women  than 
in  men.  Frequently  in 
combination  with  hys- 
terical symptoms. 


No  tumor  can  be  palpated 
unless  in  the  rare  and 
exceptional  cases  in 
which  foreign  bodies, 
such  as  hair,  etc.,  are 
introduced. 


[Hydrochloric  acid  vari- 
able.] 


No  symptoms  oiperf'^  a- 
tion. 


Gastric  Cancer. 


Slight  febrile  movement, 
but  only  in  the  presence 
of  adhesive  inflammation 
caused  by  perforation  of 
the  ulcer;  or  in  connec- 
tion with  larger  hsemor- 


Complexion  commonly 
fresh,  only  anaemic  after 
severe  losses  of  blood. 
Frequently  the  visible 
raucous  membranes  and 
even  the  cheeks  are  slight- 
ly cyanotic.  Another 
group  of  patients  is  chlo- 
rotic. 

Most  frequent  in  middle- 
aged  patients.  Rare  in 
children.  Spirits  varia- 
ble, frequently  much  de- 
pressed. 


Round,  egg-shaped  tumor 
to  the  right  of  the  mid- 
line, if  the  ulcer  is  situ- 
ated at  the  pylorus  and 
is  followed  by  hypertro- 
phy. In  old  ulcers  with 
a  firm  base  and  thickened 

•  border — or  in  circum- 
scribed encapsulated  per- 
forations, or  in  case  of 
adhesions  with  the  head 
of  the  pancreas,  the  left 
lobe  of  the  liver  or  the 
spleen — a  tumor  may  at 
times  be  palpated.  Posi- 
tion not  changed  by  re- 
spiratory movements. 

Hydrochloric  acid  present 
and  usually  increased  in 
amount. 

Perforation  into  the  neigh- 
boring organs,  with  its 
characteristic  signs  ap- 
pearing even  after  an  ap- 
parently short  duration 
of  the  disease,  or  without 
so  much  as  a  premoni- 
tion. 


Fever  rare.  When  present, 
onlv  seen  toward  the  end 
of  life. 


Complexion  pale  and  yel- 
lowish. Skin  dry  and  re- 
laxed.    Marked  cachexia. 


Most  frequent  between  forty 
and  sixty  years.  Spirits 
depressed  and  despondent, 
but  remarkably  less  de- 
spairing than  in  severe 
cases  of  ulcer. 

Tumor  variable  in  size  and 
form  :  knobbed  or  smooth  ; 
can  readily  be  palpated  ; 
usually  can  be  moved 
without  resistance  ;  at 
times  its  position  changes 
with  respiration.  Sec- 
ondary glandular  enlarge- 
ments.   Metastases. 


[In  the  majority  of  cases  no 
hydrochloric  acid,  but  an 
excess  of  lactic  acid.] 

Perforation  or  implication 
of  surrounding  organs 
only  after  the  disease  has 
existed  for  some  time.* 


*  [See  also  E.  Kollmar,  Zur  Differentialdiagnose  zwischen  Magengeschwiir  und 
Magenkrebs.     Berl.  klin.  Wochenschr.,  Bd.  xxviii,  pp.  119,  146. — Ec] 


DIAGXOSIS  OF  GASTRIC  ULCER.  421 

This  table  may  be  of  service  in  establisliing  a  differential  diag- 
nosis. However,  sliarp  as  tlie  distinction  between  the  tliree  pic- 
tures maj  appear  on  paper,  we  find  often  enough  in  practice  that 
just  the  most  important  symptoms  are  absent,  or  so  combined  with 
one  another,  or  so  vaguely  manifested,  that  an  exact  diagnosis  can 
not  possibly  be  made.  This  applies  especially  to  the  early  stages  of 
the  ulcerative  process.  Up  to  the  present  time  it  was  well-nigh 
impossible  to  differentiate  these  conditions  from  the  many  forms  of 
dyspepsia,  as  long  as  they  presented  only  more  or  less  marked  gen- 
eral disturbances  of  nutrition,  as  long  as  no  typical  gastralgic  attacks 
occurred,  and  esj^ecially  as  long  as  every  trace  of  hgematemesis  was 
absent.  I  regard  the  demonstration  of  increased  acidity  as  a  marked 
advance  toward  the  recognition  of  this  condition,  and  it  enables  us 
to  make  an  early  diagnosis.  It  is  just  in  these  cases  that  I  consider 
it  especially  valuable,  although  it  must  not  be  forgotten  that  we 
undoubtedly  find  exceptions  to  this  rule.  I  do  not  mean  by  this  to 
belittle  the  value  of  positive  results,  for  establishing  which  Riegel 
deserves  great  credit ;  nevertheless,  the  simultaneous  presence  of 
the  three  classical  symptoms — typical  gastralgia,  hsematemesis,  and 
bloody  stools,  together  with  absence  of  tumor  and  cachexia — still 
remains  the  most  positive  means  of  establishing  the  diagnosis.  Yet 
I  have  seen  cases  of  undoubted  gastric  ulcer  with  great  loss  of 
strength,  and,  on  the  other  hand,  cases  of  cancer  of  the  stomach  in 
which  the  strength  and  general  condition  were  unusually  good.  At 
times  we  can  only  make  the  diagnosis,  as  Leube  also  says,  by  the 
success  or  failure  of  specific  treatment  for  ulcer.  A  special  difii- 
culty  in  diagnosis  may  be  caused  by  the  above-mentioned  tumorlike 
cicatrization,  and  where  neighboring  organs  have  been  drawn  into 
the  base  of  the  ulcer,  which  has  become  adherent  to  them  and  per- 
forated over  them.  In  the  latter  case  the  head  of  the  pancreas  and 
the  left  lobe  of  the  liver  are  specially  involved,  less  frequently  the 
spleen.  There  is  also  a  lymphatic  gland  in  the  ligamentum  gastro- 
colicum,  and  especially  a  chain  of  glands  situated  near  by,  which 
under  certain  circumstances  become  sympathetically  swollen  and 
sensitive  on  pressure,  and  which  may  be  detected  on  palpation  as 
small  tumors  of  the  size  of  a  hazelnut  at  the  lower  edge  of  the 
stomach.     These  have  repeatedly  caused  me  great  trouble  in  diag- 


422  •  DISEASES,  OF  THE  STOMACH. 

nosis.  In  all  these  cases,  the  fact  that  the  tumor  remains  unaltered, 
the  maintenance  of  strength,  and  the  presence  of  lijdrochloric  acid, 
speak  for  the  diagnosis  of  ulcer  and  against  cancer.  Further,  as 
ma  J  be  assumed  from  what  I  have  already  said  concerning  the  du- 
ration of  these  processes,  a  course  lasting  more  than  three  years, 
and  the  absence  of  typical  cancerous  cachexia,  point  toward  the 
presence  of  the  former  affection. 

While  discussing  cancer  of  the  stomach  I  have  already  spoken 
of  the  transformation  of  an  ulcer  into  a  cancer.  Inasmuch  as  we 
know  that  hyperacidity  is  the  rule  in  the  majority  of  cases  of  gas- 
tric ulcer,  we  ought  not  to  be  surprised  to  find  a  persistence  of  the 
secretion  of  hydrochloric  acid,  sometimes  even  up  to  the  normal 
amount,  in  certain  cases  of  cancer  which  have  developed  in  this 
way.  It  is  therefore  of  importance  from  a  diagnostic  standpoint  to 
consider  tumors,  especially  those  situated  at  the  pylorus,  which  are 
accompanied  by  the  typical  symptoms  of  the  cancerous  cachexia, 
but  in  which  hydrochloric  acid  is  present  in  abundance,  as  being 
cancers  which  have  developed  from  ulcers.  I  have  repeatedly  seen 
such  cases.  In  one  of  them  a  tumor  at  the  pylorus  reached  the  size 
of  an  apple  within  a  year.  At  first  the  patient,  a  man,  twenty-seven 
years  old,  presented  only  the  symptoms  of  an  ulcer  with  hyper- 
acidity of  104  and  101  per  cent ;  this  hyperacidity  persisted  in  spite 
of  the  development  of  the  tumor  and  the  presence  of  well-marked 
signs  of  stenosis.  Gastroenterostomy  was  performed  ;  at  the  opera- 
tion inspection  of  the  tumor  showed  that  it  was  undoubtedly  a 
cancer.  Dietrich*  has  estimated  the  frequency  of  such  cancers  to 
be  5  per  cent  of  all  gastric  carcinomas ;  Rosenheim  f  places  it  even 
higher,  8  per  cent. 

The  Diagnostic  Use  of  the  Tube  in  Ulcer. — The  question  arises 
whether  it  is  justifiable  to  introduce  the  stomach  tube  for  diagnos- 
tic purposes  in  gastric  ulcer.  Many  clinicians,  of  whom  I  shall 
only  mention  Leube  among  the  Germans  and  Germain  See  %  among 
the  French,  condemn  lavage  and  the  use  of  the  tube  in  this  con- 
dition.    See  cites  cases  of  Cornillon  and  Daguet  in  which  lavage 

*  Loc.  cit.  t  Berl.  klin.  Wochenschr.,  1889,  No.  47. 

X  Gr.  See.    Hyperchlorhydrie  et  atouie  de  I'estomac.    Bull,  de  I'Acad.  de  med.,  1 
mai,  1888. 


DIFFERENTIAL  DIAGNOSIS  OF   H^MATEMESIS.  423 

was  followed  by  fatal  lisemorrliages.  My  own  opinion  is  tliat  tlie 
tube  may  be  employed  after  preliminary  cocainization  of  the  fauces, 
and  in  connection  witli  the  aspiration  method ;  but  its  use  must  be 
restricted  to  those  cases  in  which  a  diagnosis  can  not  be  established  in 
any  other  way.  For  scientific  purposes  we  may  risk  the  possible 
dangers  in  a  clinic  or  hospital  where  the  necessary  means  are  at 
hand  in  case  of  emergency ;  but  in  private  practice  and  in  dispen- 
sary work  I  must  caution  against  it  most  decidedly,  otherwise  I  fear 
one  may  at  some  time  find  himself  in  an  exceedingly  uncomfortable 
position.  It  may  happen  to  any  one  that  in  introducing  the  tube 
we  may  cause  haemorrhage,  and  may  even  be  so  unfortunate  as  to 
cause  the  perforation  of  an  unsuspected  ulcer,  or  of  one  giving 
but  vague  symptoms.  This  might  easily  have  happened  to  me  in 
the  case  reported  on  page  377,  just  as  it  did  in  the  one  quoted  later 
on,  without  giving  rise  to  any  justifiable  reproach.  But  this  danger 
must  always  be  borne  in  mind.  It  is,  of  course,  greatly  lessened  by 
cocainizing  the  throat  before  introducing  the  tube  in  doubtful  cases, 
and  by  using  the  utmost  caution  in  aspirating  with  the  aspirator  or 
the  stomach  pump ;  it  is  equalized,  and  more  than  equalized,  by  the 
great  advantages  peculiar  to  our  methods  of  examination.  But, 
nevertheless,  I  refrain  from  introducing  the  tube  in  all  cases  of 
ulcer  in  which  the  diagnosis  can  he  made  in  another  way ;  and  I 
desist  so  much  the  more,  since  in  these  cases  the  examination  of 
the  stomach  contents  does  not  estcd)lish  the  diagnosis^  and  since  it 
does  not  aid  us  in  the  treatment.  On  the  other  hand,  I  have  ob- 
served that  severe  hsemorrhages  which  could  not  be  controlled  in 
any  other  way  have  been  checked  by  washing  out  the  stomach  with 
ice-cold  water,  as  will  be  discussed  later  on  under  the  treatment. 

Differential  Diagnosis  of  Hsematemesis. — As  the  expression  "  vom- 
iting of  blood  "  is  applied  not  only  to  gastric  but  also  to  pulmonary 
haemorrhages,  we  may  consider  the  differences  between  them — i.  e., 
between  hcBmatemesis  and  hcemoptysis.  "We  must  remember  that 
in  haemoptysis  the  blood  is  mixed  with  a  great  deal  of  air  and  con- 
sequently tends  to  be  bright  red  in  color,  and  is  ejected  by  cough- 
ing, and  also  that  the  history  points  to  some  chronic  pulmonary  af- 
fection. In  many  cases  the  patients  have  a  distinct  sensation  as  to 
28 


424  DISEASES  OP   THE  STOMACH. 

whetlier  tlie  blood  comes  from  the  lungs  or  from  the  stomach ;  in 
the  former  the  haemorrhage  is  preceded  by  inclination  to  cough,  due 
to  irritation,  tickling  in  the  throat,  and  a  sensation  of  warmth  in  the 
chest,  while  in  gastric  haemorrhages  nausea  and  a  tendency  to  vomit 
precede  the  attack.  This  holds  true  also  of  pharyngeal  haemor- 
rhages, which  may  possibly  come  into  play  here  ;  but  these,  as  a 
rule,  are  not  so  profuse,  their  source  can  usually  be  easily  discov- 
ered, and  the  attack  generally  occurs  under  circumstances  which  do 
not  permit  their  being  mistaken.  However,  gastric  haemorrhages 
may  begin  very  violently,  coughing  being  caused  by  the  aspiration 
of  blood  into  the  respiratory  tract,  which  is  expelled  not  only 
through  the  mouth  but  also  through  the  nose.  Thus  a  pulmonary 
haemorrhage  may  be  simulated,  and  even  suffocation  produced,  by 
blood  accumulating  and  clotting  in  the  throat  during  syncope.  In 
haemoptysis  the  patients  cough  for  some  time,  and  the  sputa  are 
coin-shaped  and  brownish  or  brownish-red  in  color  ;  in  a  recent  at- 
tack we  first  observe  bright-red  and  then  dark  blood.  There  is  no 
sputum  after  haematemesis,  but,  as  a  rule,  we  find  bloody  stools 
(i,  e.,  so-called  melaena),  which  in  doubtful  cases  indicate  the  occur- 
rence of  gastric  haemorrhage.  On  the  other  hand,  we  naturally  dare 
not  forget  that  many  gastric  haemorrhages  occur  without  bleeding 
from  the  intestine,  and  also  that  occasionally  blood  which  has  been 
coughed  up  is  swallowed  and  voided  in  the  stools. 

The  causes,  then,  which  lead  to  haematemesis,  disregarding  ulcer 
and  carcinoma,  are  : 

1.  Conditions  of  congestion  in  the  venous  vascular  system. 
Thus  Dr.  Yellowly  *  reports  a  case  of  haemorrhage  into  the  stomach 
in  a  man  who  was  hanged  (at  all  events,  there  was  no  haematemesis). 
Similar  occurrences  are  said  to  take  place  in  epileptic  attacks. 
Cases  of  haematemesis  with  cardiac  lesions  have  been  described  by 
Carswell  and  Budd.f  H.  Jones  X  b^s  reported  a  case  in  acute  yel- 
low atrophy  of  the  liver,  and  another  in  cirrhosis  of  the  liver  with 
compression  of  the  portal  vein.     Debove  *  has  published  an  exLaust- 

*  Med.-Chirurg.  Transactions,  1853.  f  Loc.  cit.,  p.  53. 

X  H.  Jones.     Cases  of  Hfematemesis,  with  Remarks.     Med.  Times  and  Gazette, 
1855,  vol.  ii,  pp.  182,  410. 

*  Debove.     Des  hemorrhagies  gastro-intestinalcs  profuses  dans  la  cirrhose  du 
foie  et  dans  les  autres  affections  hepatiques.     Journ.  Soc,  anatom.,  1890,  No.  43. 


DIFFERENTIAL   DIAGNOSIS   OF  H^EMATEMESIS.  405 

ive  essay  upon  the  relation  between  lisematemesis  and  diseases  of  the 
liver.  Here  especial  attention  must  be  paid  to  the  hsemorrhage  from 
dilated  cesophageal  veins.  In  hepatic  cirrhosis  these  vessels,  which 
form  a  part  of  the  collateral  circulation  for  the  blood  in  the  portal 
vein,  are  liable  not  alone  to  well-marked  varicosities  but  also  to  rup- 
tures which  may  cause  profuse  and  at  times  even  immediately  fatal 
haemorrhages.  If  the  blood  flows  into  the  stomach  and  is  then  vom- 
ited, it  may  simulate  haemorrhage  from  the  stomach ;  if,  then,  an 
autopsy  be  performed  on  such  a  case  without  paying  the  proper  at- 
tention to  the  oesophagus,  the  diagnosis  of  so-called  idiopathic  gas- 
tric haemorrhage  will  be  made.  The  number  of  such  cases  reported 
has  grown  remarkably  since  attention  has  been  called  to  them. 
Blume,  Stony  Wilson,  Litten,  Sachs,  Yoelkel,  and  Ewald  *  have  pub- 
lished and  described  cases  of  this  kind.  [At  the  May  (1896)  meet- 
ing of  the  Association  of  American  Physicians  Garland  reported  a 
case  of  oesophageal  haemorrhage  with  cirrhosis  of  the  liver.  In  the 
discussion  Osier  described  two  cases.  Graham  mentioned  a  case  of 
cesophageal  haemorrhage  in  a  boy  ;  at  the  autopsy  oesophageal  vari- 
cosities were  found,  but  no  disease  of  the  liver  or  any  other  organ. 
Mitchell  added  another  case  of  a  child  who  died  of  unaccountable 
haemorrhage  after  scarlet  fever.  The  autopsy  showed  large  "oeso- 
phageal piles,"  and  also  a  group  of  dilated  veins  in  the  stomach,  but 
no  disturbance  of  any  other  organ. f] 

Sachs's  case  is  particularly  interesting,  as  its  clinical  cause  was  very 
much  like  the  one  I  have  reported.  A  sixty-year-old  man  had  for  years 
repeated  profuse  hEemorrhages  from  the  stomach ;  at  first  they  were  in- 
frequent, later  they  occurred  every  half  year,  and  finally  every  three 
months.  Gastric  symptoms,  pain  on  ijressure.  and,  in  fact,  all  signs  of  any 
abdominal  disease  were  absent.  The  haemorrhages  were  preceded  by  ver- 
tigo, cold  sweats,  etc. ;  they  were  followed  by  a  feeling  of  relief.  Finally 
he  became  intensely  anaemic  and  weak,  and  died  immediately  after  a  pro- 
fuse haemorrhage.  The  autopsy,  the  very  interesting  details  of  which  I 
can  only  indicate,  revealed  an  aneurism  of  the  hepatic  artery  which  had 
ruptm-ed  into  a  hepatic  vein ;  thrombosis  of  the  splenic  vein,  and  a  rup- 
tured varix  at  the  cardia.  Manifestly  the  oesophageal  veins  were  the 
source  of  the  recurrent  ha?morrhages. 

*  Blurae.  Ora  phlebectasia  et  varices  cesophagi,  etc.  Copenhagen,  1868. — 
Stony  Wilson.  Brit.  Med.  Journ.,  December  27.  1890. — Litten.  Yerhandlungen 
des  X.  internat.  med.  Congresses  zu  Berlin. — Sachs.  Deutseh.  med.  Wochenschr,, 
1892,  No.  20.— Ewald.     Ibid.,  No.  20,  Verhandl.  des  Yereins  f,  innere  Med. 

t  [Medical  News,  May  23,  1896,  p.  595.— Ed.] 


426  DISEASES  OP  THE  STOMACH. 

In  a  case  of  cirrhosis  of  the  liver  with  fatal  haemorrhage,  the  diagnosis 
was  made  during  life,  because  the  heematemesis  occurred  without  any 
nausea  or  gagging ;  indeed,  there  were  no  premonitory  symptoms  at  all ; 
this,  together  with  the  presence  of  the  hepatic  cirrhosis,  rendered  the  lia- 
bility of  such  an  occurrence  as  rupture  of  an  oesophageal  varix  very  likely. 
At  the  autopsy  I  found  a  ruptured  varicose  vein  in  the  lower  portion  of 
the  oesophagus. 

Yomiting  of  blood  is  also  said  to  occur  in  intermittent  and  ty- 
phoid fevers,  but  in  the  cases  described  the  existence  of  an  ulcer  is 
not  excluded.* 

2.  Active  hyj>er(Bmia.  An  example  of  this  is  found  in  the  fre- 
quently quoted  case  of  Watson,f  concerning  a  woman  who  ever 
since  her  fourteenth  year  had  gastric  haemorrhage  instead  of  men- 
struating, which  after  her  marriage  only  ceased  during  pregnancy 
and  lactation,  and  then  became  vicarious  as  before.  The  following 
case,  which  came  under  my  observation,  must  also  be  considered 
among  the  active  hypersemias : 

The  patient  was  a  married  woman,  who  again  became  pregnant  after 
having  already  borne  two  children,  the  younger  of  which  was  one  year 
old.  One  evening,  in  order  to  bring  about  a  miscarriage,  she  drank  a 
hot  decoction  consisting  of  a  bottle  of  claret,  chamomile  flowers,  juniper 
berries,  and  some  powerful  aromatics,  and  also  took  a  vaginal  injection 
of  soap- water.  During  the  night,  while  nursing  the  baby,  she  suddenly 
fainted,  and  vomited  large  quantities  of  fresh  blood.  This  was  followed 
by  rectal  tenesmus  and  the  evacuation  of  bloody  masses.  The  hcemateme- 
sis  recurred  twice  during  the  next  three  days.  Although  she  was  greatly 
prostrated,  she  made  an  excellent  recoveiy  under  appropriate  treatment. 
Strange  to  say,  she  did  not  abort.  No  gastric  symptoms  occurred  during 
the  following  three  years. 

Here,  too,  the  haemorrhages  in  severe  chronic  glandular  gastritis 
are  to  be  included,  which  probably  may  be  regarded  as  analogous 
to  the  bleeding  in  chronic  catarrh  of  the  nose  and  pharynx.  Usu- 
ally they  are  so  slight  that  they  do  not  cause  vomiting  of  blood. 
Finally,  we  may  also  include  the  rarer  hsematemesis  in  hysterical 
subjects,  in  cholera,  yellow  fever,  scurvy,  purpura  hasmorrhagica, 
helminthiasis,  malaria,  and  exanthemata,  so  far  as  the  hemorrhage  is 

*  M.  Weiss.  Magenblutungen  bei  Typhus  abdominalis.  Wiener  med.  Presse, 
1887,  No.  12.— Millard.  L'Union  Med., 'l877,  No.  13.— Reimer.  Jahrb.  fur  Kin- 
derheilkunde,  Neue  Folge,  Bd.  x,  p.  39, 

t  Cited  by  Budd,  loc.  cit,  p.  364. 


DIAGNOSIS  OF   H^MATEMESIS.  427 

not  dependent  upon  direct  lesions  to  the  vessels,  or  upon  changes  in 
their  walls. 

But  large  hsemorrhages  undoubtedly  occur  in  the  stomach,  in 
which  no  changes  in  the  blood-vessels  can  be  found. 

In  1891  a  young  man,  twenty-four  years  old,  was  admitted  to  the  medi- 
cal division  of  the  Augusta  Hospital ;  he  complained  of  moderate  dyspep- 
tic symptoms ;  there  was  no  fever,  vomiting,  or  sign  of  a  severe  acute  or 
chronic  disease.  On  the  tliird  day  he  went  into  collapse  with  all  the 
symptoms  of  internal  haemorrhage.  At  the  autopsy  the  stomach  was 
found  distended  with  fresh  and  partly  coagulated  blood,  but  the  most 
careful  examination  of  the  entire  digestive  tract  failed  to  reveal  any 
cause  for  the  bleeding.  Hepatic  cirrhosis,  typhoid  fever,  or  any  general 
disease  which  might  be  associated  with  the  haemorrhage  was  not  present, 
and  hence  by  exclusion  the  diagnosis  of  "parenchymatous"  haemorrhage 
was  made. 

Likewise  the  diagnosis  of  the  following  case  is  doubtful  at  least, 
in  spite  of  repeated  haemorrhages,  although  in  my  opinion  the 
occurrence  of  capillary  or  parenchymatous  haemorrhage  is  the  most 
plausible. 

The  patient  was  a  man,  sixty-seven  years  old,  in  very  good  circum- 
stances, and  of  a  strong  and  vigorous  constitution,  who  had  come  to  Berlin 
for  consultation  on  account  of  severe  haematemesis  which  had  occurred  a 
short  time  previous.  His  physician  wrote  :  "  On  January  25,  1890,  I  was 
suddenly  called  to  see  Mr.  Q.  on  account  of  severe  cardialgia,  for  which 
he  wished  a  hypodermic  injection  of  morphine.  The  latter  at  once 
stopped  the  pain,  but  he  vomited  acid  stomach  contents.  In  the  evening 
there  was  coffee-ground  vomit ;  on  the  next  day  over  a  litre  of  dark,  fluid 
blood  was  raised.  There  was  no  fever  ;  the  pulse  was  110 ;  systolic  mur- 
mur heard  over  the  cardiac  area.  On  the  next  day  haematemesis  occurred 
once ;  then  the  patient  recovered  so  rapidly  that  he  was  scarcely  a  week 
in  bed,  and  went  out  riding  on  February  2d.  Soon  after,  the  patient's 
appearance  was  excellent.  Exactly  one  year  previous  he  had  had  similar 
attacks  of  profuse  haematemesis ;  went  to  Carlsbad  and  Baden  Baden, 
and  was  perfectly  well  and  exceptionally  strong  during  the  whole  year 
of  1889.  Every  time  the  bleeding  occurred  while  the  patient  was  per- 
fectly ivell  after  too  great  exertions,  and  each  time  was  immediately 
followed  by  months  of  health.  There  are  no  alcoholic  excesses,  but  his 
work  is  excessive  and  irregular." 

On  February  14,  1890, 1  examined  him  and  was  unable  to  make  a  posi- 
tive diagnosis,  for  nothing  was  found  except  a  systolic  murmur  at  the 
apex  of  the  heart.  In  my  case  book  I  entered  the  diagnosis  ulcer  (?)  or 
varicosities  (?). 

At  my  request  his  physician  sent  me  the  following  report  on  January 
3,  1893  :  "  Since  his  visit  to  you  the  patient  has  had  a  number  of  similar 
attacks  of  bleeding  without  his  general  condition  being  in  any  way 


428  DISEASES  OF  THE  STOMACH, 

affected  by  them.  This  is  all  the  more  remarkable  because  he  is  very 
reckless.  A  trip  to  Italy  and  back  within  a  fortnight  in  midwinter  is  a 
mere  trifle  to  him.  He  is  now  seventy  years  old,  and  is  apparently  in 
good  physical  and  mental  condition.  The  only  restraint  he  places  upon 
himself  is  a  proper  diet  and  abstinence  from  alcohol." 

Hood  *  has  repeatedly  observed  such  haemorrhages  with  rapid 
recovery  in  young  angeniic  girls  and  women,  without  a  tj^pieal  his- 
tory or  symptoms  of  ulcer.  He  describes  several  excellent  exam- 
ples of  this  kind.  In  looking  over  my  records  I  can  also  find  a 
number  of  cases  which  I  had  diagnosticated  as  haemorrhage  from 
ulcers,  but  the  histories  of  which  are  so  little  characteristic  of  ulcer 
that  they  may  also  be  interpreted  from  this  standpoint  of  Hood, 
provided  we  accept  his  views  as  correct.  These  cases  occurred  in 
anaemic  women  from  eighteen  to  thirty  years  old. 

3.  Direct  traumatisms.  Hafner  f  reports  the  case  of  a  boy  who 
half  an  hour  after  a  fall  from  a  considerable  height  on  hard  ground, 
without  apparent  external  injury,  repeatedly  vomited  blood,  and  had 
bloody  stools.  The  swallowing  of  pointed  objects,  and  even  severe 
vomiting  itself,  without  any  further  injury,  may  lead  to  gastric 
haemorrhage.  Pointed  bodies  which  have  teen  swallowed  may 
cause  severe  vomiting  and  h^matemesis  without  causing  any  further 
injury  to  the  stomach.  Heilbrunn  %  reports  a  case  in  which  blood 
was  vomited  after  drinking  a  glass  of  beer ;  in  the  wash-water  he 
found  a  sharp  triangular  piece  of  glass  from  the  bottle,  1  ctm.  [04 
inch]  long  and  2  mm.  [-08  inch]  thick.     The  patient  recovered. 

4.  Alterations  in  the  walls  of  the  Uood-vessels.  As  yet  nothing 
is  known  concerning  the  formation  of  varices  or  of  atheromatous  or 
amyloid  degeneration  of  the  gastric  vessels,  which  might  lead  to 
haemorrhages.  However,  where  a  positive  and  extensive  change  in 
the  vessels  exists,  as,  for  instance,  in  the  atheroma  of  old  persons,  it 
does  not,  according  to  my  experience,  lead  to  gastric  haemorrhage. 
As  already  stated,  varicose  veins  occur  in  the  oesophagus  in  old  per- 
sons, and  also,  as  stated  by  Letulle,*  in  confirmed  drunkards ;  bleed- 
ing from  these  vessels  may  give  rise  to  false  haemorrhages  from  the 

*  Loc.  cit.  t  Cited  by  Henoch,  p.  434, 
X  Heilbrunn.     Centralbl.  fiir  Chirurgie,  1891,  No.  6. 

*  Letulle.    Varices  veineuses  de  I'oesophage  dans  ralcoolisme.     Jour,  des  societ. 
Sclent.,  1890. 


DIAGNOSIS   OF   H^EMATEMESIS.  4,29 

stomacli.  This  will  coincide  witli  the  above-described  htemorriiages 
in  cirrhosis  of  the  liver.  I  have  found  two  cases  reported  by  Gal- 
liard  *  as  examples  of  the  only  disease  which'  can  be  classed  under 
this  heading,  in  which  small  miliary  aneurisms  were  the  cause  of 
rapidly  fatal  and  very  j)rofuse  gastric  haemorrhage.  Both  patients 
were  men,  twenty-five  and  fiity-one  years  old  respectively.  Athe- 
roma, or  other  diseases  of  the  general  vascular  system,  were  said  not 
to  be  present.  Additional  cases  have  been  reported  by  Sachs  +  and 
Welch ;  if  in  a  man,  fifty  years  of  age,  he  found  a  raptured  mihary 
aneurism  on  a  branch  of  the  gastric  artery ;  it  was  situated  in  the 
submueosa,  midway  between  the  pylorus  and  cardia. 

It  is  apparent  that  the  recogTiition  of  the  cause  of  the  hsemor- 
rhage,  the  difficulties  of  which  I  have  already  discussed  (page  4'J7j, 
necessitates  different  lines  of  treatment,  and  that  it  can  not  be 
an  indifferent  matter,  either  for  the  prognosis  or  the  treatment, 
whether  the  hsematemesis  be  due  to  a  congestion,  or  an  active  hy- 
persemia,  or  a  destructive  process  acting  on  the  mucous  membrane. 

Here  I  wish  to  direct  attention  to  an  apparently  secondary  mat- 
ter, but  which  to-day  plays  an  important  role  in  the  examination  of 
the  faeces.  I  refer  to  the  use  of  water  closets.  Many  patients, 
unless  confined  to  bed,  are  unable  to  describe  their  dejecta,  be- 
yond speaking  of  the  vague  impression  that  they  are  formed  or 
otherwise,  or  that  the  quantity  is  large  or  normal  or  small,  because 
they  never  see  their  stools.  Therefore  we  can  never  be  positive  of 
a  possible  bloody  evacuation,  as  well  as  of  many  other  facts.  A 
striking  example  of  this  is  the  following  case  quoted  from  mv  case 
book  : 

A  man,  thirty-eight  years  old,  had  suffered  for  five  years  with  stomach. 
disturbances  which  at  first  manifested  themselves  only  in  a  feeling  of  full- 
ness in  the  stomach  after  eating-,  occasional  belching,  and  constipation. 
Strict  diet  and  medication,  together  Tvith  the  use  of  Carlsbad  iMiililbrun- 
nen)  water,  only  gave  slight  relief.  True  cardialgia  never  present.  One 
day,  a  year  ago.  he  had  abdominal  pains  and  diarrhoea  Tvhile  at  his  office, 
necessitating  his  using  the  closet  several  times  during  the  day.  Toward 
evening  he  suddenly  fainted,  and  was  carried  home  half  dead.     He  re- 

*  Galliard.  Alterations  peu  connues  de  la  muqueuse  de  restomac.  Gaz.  d.  hopit., 
1884,  p.  196. 

f  Sachs,  loc.  cit. 

X  Welch.    Johns  Hopkins  Hospital  Bulletin,  Xo.  1. 


430  DISEASES  OF  THE  STOMACH. 

mained  in  bed  five  weeks,  and  recovered  slowly.  Was  quite  well  the  fol- 
lowing suramer,  complaining-  only  of  slight  gastric  oppression.  Now,  for 
about  eight  weeks,  he  has  had  great  difficulty,  especially  marked  regurgi- 
tation and  repeated  vomiting  some  time  after  eating,  chiefly  during  the 
night  between  ten  and  twelve  and  two  and  three  o'clock.  Relief  after 
voraiting.  He  claims  that  there  never  was  any  blood  in  the  vomit  or 
f^ces.     Constipated.     Feeling  of  fatigue  marked. 

With  the  exception  of  slight  sensitiveness  on  pressure  nothing  could 
be  discovered  either  in  the  epigastrium,  or  to  the  right  of  this  in  the  para- 
sternal line  under  the  free  border  of  the  ribs.  The  acidity  after  the  test 
breakfast  was  84 — i.  e.,  hyperacidity  was  present. 

Tliere  can  be  no  doubt  that  this  was  a  case  of  gastric  or  duodenal 
ulcer,  and  tbat  the  apparent  "  diarrhoea  "  was  the  resulting  profuse 
haemorrhage  leading  to  fainting,  for  the  other  conditions  causing 
hsemorrhage  from  the  bowels,  such  as  tuberculosis,  ulcers,  diseases 
of  the  portal  vein  and  of  the  liver,  etc.,  could  be  excluded.  Later  on 
the  patient  remembered  that  he  had  seen  blood  on  the  closet  paper. 
How  often,  however,  may  such  haemorrhages  occur  without  coming 
to  the  knowledge  of  the  patient  or  of  the  physician.  Only  a  short 
time  ago  I  had  another  case  of  this  kind  in  which  a  man,  suffering 
with  gastralgia,  after  a  short  sojourn  in  Carlsbad,  had  two  severe 
attacks  of  syncope,  which,  now  that  symptoms  of  a  duodenal  ulcer 
have  become  more  plainly  developed,  can  only  be  referred  to  severe 
internal  intestinal  haemorrhage. 

Considerable  difficulty  may  arise  in  making  a  differential  diag- 
nosis between  hepatic  and  renal  colic  and  gastralgia  due  to  an  ulcer 
at  the  pylorus  or  in  the  duodenum.  J^aturally,  not  in  the  typical 
cases  of  either  disease.  Just  as  positively  as  the  complete  list  of 
symptoms  given  above  shows  the  presence  of  an  ulcer,  we  may  es- 
tablish a  diagnosis  of  hepatic  colic  if  we  find  constantly  recurring 
pain  in  the  right  hypochondrium  independent  of  the  ingestion  of 
food,  possibly  mild  febrile  movements,  jaundice,  swelling  of  and 
pain  over  the  liver,  together  with  a  gall  bladder  which  may  be  pal- 
pated, possibly  with  gall-stones,  shooting  pains  along  the  ureters, 
haematuria,  and  the  passage  of  biliary  or  renal  calculi.  But  very 
many  cases  occur  in  which  the  symptoms  are  so  shifted  about  that 
we  can  scarcely  avoid  mistaking  one  for  the  other.  If  in  cases  of 
hepatic  colic  jaundice  may  frequently  be  absent  or  very  slight,  so, 
on  the  other  hand,  we  not  uncommonly  find  cases  of  gastralgia  with 


DIAGNOSIS  OF  GASTRIC   ULCER.  431 

slight  icterus,  due  perhaps  to  the  convulsive  contraction  of  the  ab- 
dominal viscera  forcing  the  bile  into  the  blood,  or  perhaps  because 
a  very  transient  sympathetic  spasm  of  the  hepatic  duct  has  caused 
a  stagnation  of  the  bile.  Frequently,  too,  the  patients  refer  the 
pain  in  hepatic  colic  more  toward  the  mid-line,  especially  the  case 
in  women,  in  whom  lacing  has  altered  the  topography  of  the  liver. 
Should  the  pylorus  be  disj)laced  somewhat  toward  the  right,  or 
should  the  ulcer  lie  in  the  horizontal  portion  of  the  duodenum,  a 
local  diif  erentiation  would  be  wholly  out  of  the  question.  Thus  we 
may  remain  in  doubt  for  along  time,  or  indeed  never  decide  whether 
we  have  to  deal  with  hepatic  colic  or  with  gastralgia.  Here,  agaiu, 
the  presence  of  hyperacidity  of  the  gastric  contents  offers  us  a  val- 
uable diagnostic  aid.  Results  in  which  the  acidity  amounts  to  more 
than  80 — i.  e.,  0*3  per  cent  of  hydrochloric  acid — may  be  regarded 
as  denoting  this. 

l!^ot  only  is  the  diagnosis  of  the  existence  of  an  ulcer  to  be  es- 
tablished, but  its  site  as  well.  This  assertion  has  frequently  been 
made,  only  lately  even  by  Gerhardt.  According  to  my  conviction 
and  experience,  it  is  only  possible  in  those  cases  in  which  the  cir- 
cumstances are  unusually  favorable,  that  an  ulcer  situated  at  the  py- 
lorus or  in  the  duodenum,  or  perhaps  on  the  greater  curvature,  may 
be  made  out.  On  the  other  hand,  proceeding  by  exclusion,  we  may 
surmise  that  the  site  of  the  ulcer  is  elsewhere.  In  contrast  to  this, 
ulcer  of  the  pylorus  can  be  recognized  by  a  sharply  localized  pain  a 
little  to  the  right  of  the  middle  line.  But  the  element  of  time  as  a 
factor  in  the  causation  of  the  pain  now  leaves  us  in  the  lurch,  and  I 
find  the  assertion  that  ulcers  in  the  cardiac  portion  of  the  stomach 
are  accompanied  by  pain  immediately  after  eating,  while  those  at 
the  pylorus  only  cause  pain  later,  to  be  neither  sufficiently  proved 
clinically  nor  warranted  under  the  circumstances.  We  really  can 
not  conceive,  or  at  least  we  have  no  grounds  for  so  doing,  that  the 
ingesta  are  retained  at  the  cardia  and  only  reach  the  pylorus  after 
an  appreciable  interval.  Attempts  have  also  been  made  to  locate 
the  site  of  the  ulcer  by  the  position  which  some  patients  assume  in 
order  to  ease  the  pain.  If  the  pain  is  lessened  when  the  patient  hes 
on  the  left  side,  the  ulcer  is  said  to  be  situated  on  the  lesser  curva- 
ture, and  vice  versa.     This,  too,  may  be  considered  a  doubtful  and 


4:32  DISEASES  OP  THE  STOMACH. 

unreliable  symptom — the  more  so  since  tlie  majority  of  patients 
have  no  such  experience.  If  the  site  of  the  ulcer  in  the  stomach 
were  discovered,  it  would  perhaps  be  of  practical  significance  in  pre- 
dicting the  possible  resulting  conditions.  According  to  Gerhardt,* 
"  sensitiveness  on  pressure  and  a  tumor  "  point  "  more  toward  the 
site  being  on  the  anterior  wall,  pain  in  the  back  and  haemorrhage 
more  to  its  being  on  the  posterior  wall.  Ulcers  in  the  regions  of 
the  fundus  or  the  pylorus  may  often  be  distinguished  by  the  loca- 
tion of  the  pain  and  by  its  increase  in  the  lateral  posture.  Ulcers 
of  the  fundus  which  are  adherent  to  the  spleen  may  lead  to  chills, 
owing  to  splenitis,  as  I  (Gerhardt)  have  seen  in  three  cases."  It 
need  not  be  specially  mentioned  that  dilatation  of  the  stomach  points 
to  the  site  of  the  ulcer  being  at  the  pylorus  or  in  the  duodenum,  and 
that  contraction  shows  that  it  is  at  the  cardia.  However,  if  one  con- 
siders how  vague  a  symptom  sensitiveness  on  pressure  is  ;  how  rare 
the  occurrence  of  a  tumor  caused  by  an  ulcer  is  in  comparison  with 
the  total  number  of  cases ;  how  little  we  are  able  to  establish  the 
condition  of  contraction  during  life  ;  and  if  one  will  recall  the  case 
of  perforation  of  a  necrotic  carcinoma  of  the  lesser  curvature  accom- 
panied by  chills,  cited  on  page  335  ;  and,  finally,  if  one  knows  that 
frequently  numerous  ulcers  are  situated  in  different  places,  the  un- 
reliability of  these  signs  will  be  readily  appreciated. 

Duodenal  Ulcers. — All  that  has  been  said  concerning  the  site  of 
the  ulcer  in  the  stomach  refers  also  to  its  position  in  the  duodemim. 
In  at  least  90  per  cent  of  the  cases  it  is  impossible  to  decide  posi- 
tively whether  we  are  dealing  with  a  gastric  or  a  duodenal  ulcer ; 
for  the  duodenum,  and  especially  its  horizontal  portion,  may  for 
this  purpose  be  really  regarded  as  only  a  continuation  or  a  portion 
of  the  stomach ;  and  the  ulcerative  process  is  accompanied  by  the 
same  phenomena  in  this  case  as  it  is  in  the  other.  Those  factors 
which  indicate  an  ulcer  at  the  pylorus  also  speak  for  the  duodenal 
ulcer,  and  the  more  so  since  the  latter  at  times  extends  directly 
from  the  pylorus  into  the  duodenum.  A  duodenal  ulcer  is  probably 
present  if  the  pain  does  not  develop  until  some  time  after  the  in- 
gestion of  food,  if  the  position,  together  with  sensitiveness  on  pres- 
* 

*  Loc.  cit. 


[PROGNOSIS   OF   GASTRIC   ULCER.  433 

sure,  is  situated  decidedly  to  the  riglit  of  the  parasternal  line,  and 
if  possibly  there  are  profuse  bloody  stools  without  any  hsematemesis. 
The  fact  that  duodenal  ulcers  often  appear  after  extensive  cutaneous 
burns  may  in  such  cases  be  of  service  in  diagnosis.  A  point  of 
support,  but  no  more,  is  offered  by  the  rarer  occurrence  of  ulcer  of 
the  duodenum.  Thus  Willigk  reports  only  6  duodenal  ulcers  to 
225  in  the  stomach,  and  Trier  places  the  figures  at  28  to  261.  Yet 
even  in  this  small  percentage  a  number  of  cases  are  included  in 
which  ulcers  existed  in  the  stomach  and  duodenum  at  the  same 
time.  Gastralgia  is  said  to  be  less  common  because,  as  Budd  be- 
lieves, the  duodenum  is  not  subjected  to  as  much  traction  and 
change  of  position  as  the  stomach.  Moreover,  the  very  uncommon 
appearance  of  jaundice  can  be  of  no  more  aid  in  diagnosis  than  the 
circumstance  that,  on  the  whole,  intestinal  haemorrhages  are  more 
frequent  here  than  hsematemesis,  for  we  find  that  ulcer  of  the 
stomach  alsa  leads  to  the  former,  and  that  duodenal  ulcer  is  also 
accompanied  by  the  latter.  Oppenheimer  ^  reports  a  case  in  which 
Leube  made  the  diagnosis.  An  absolutely  certain  case  of  this  kind 
I  have  had  reported  by  Reckmann.f 

Prognosis.— Till  within  a  short  time  it  was  customary  and  proper 
to  give  a  doubtful  prognosis  in  cases  of  gastric  ulcer,  when  the  diag- 
nosis could  only  be  made  by  the  established  symptoms.  But  now, 
since  we  are  able  to  recognize  its  early  stages,  and  to  differentiate  it 
from  other  dyspepsias,  since  the  principles  of  treatment  have  be- 
come apparent  to  us,  and  we  are  in  the  position  to  apply  them  at 
the  commencement  of  the  process,  the  prognosis  has  become  essen- 
tially better  so  far  as  the  early  stages  of  the  ulcer  are  concerned. 
We  may  now,  if  the  patients  subject  themselves  to  a  rational  course 
of  treatment — -i.  e.,  the  rest  cure — at  the  proper  time,  give  them 
well-grounded  prospects  of  recovery  ;  and  even  in  cases  of  classical 
ulcer  we  may  hope  for  cure  or  for  decided  improvement.  It  is  to 
be  regretted  that  during  the  earliest  stages,  which  are  not  very 
troublesome  subjectively,  very  few  patients  are  either  willing  or  in 
the  position  to  subject  themselves  to  a  course  of  treatment  which  is 

*  H.  Oppenheimer.     Das  ulcus  peptieum  duodenale.     Inaug.  Dissert.,  Wiirz- 
burg,  1891. 

f  Reckmann.     Inaug.  Dissert.,  Berlin,  1893. 


434  DISEASES  OF  THE  STOMACH. 

always  exacting.  However,  if  we  succeed  in  permanently  remedy- 
ing the  anomalies  in  the  composition  of  the  blood  or  the  secretion 
of  gastric  juice,  we  lessen  the  danger  of  relapses,  which  otherwise 
always  threaten  us,  and  only  too  often  appear.  But  the  conse- 
quences of  traction  by  the  cicatrices,  especially  after  the  healing  of 
extensive  ulcers,  always  remain  to  be  feared,  as  well  as  the  accom- 
panying permanent  impairment  of  the  general  health  which  can  not 
be  remedied.  In  such  cases,  therefore,  the  prognosis  must  always 
be  made  with  great  care.  But  that  it  is  nevertheless  not  a  poor  one 
can  be  deduced  from  the  well-known  fact  that  the  scars  of  gastric 
ulcers  are  found  about  twice  as  often  as  the  ulcers  themselves.  In 
haemorrhage,  if  this  is  not  immediately  fatal,  the  prognosis  is  on 
the  whole  favorable.  As  a  rule  we  are  able  to  control  the  bleeding 
by  means  of  appropriate  treatment,  and  even  to  remedy  extreme 
anaemia  in  a  relatively  short  time. 

Treatment. — I  know  but  one  form  of  treatment  which  holds  out 
prospects  of  success,  and  which,  if  applied  in  the  early  stages,  can 
show  excellent  results.  This  is  the  rest  cure  introduced  into  Ger- 
many by  Yon  Ziemssen  *  and  Leube,f  by  which  the  stomach  is  pro- 
tected from  all  irritating  factors,  as  a  broken  bone  is  immobilized 
in  plaster,  with  of  course  the  difference  that,  while  this  is  absolute 
in  the  latter  instance,  it  can  only  be  approximately  attained  in  the 
former.  The  principle  of  this  treatment,  long  since  recommended 
in  England  by  Wilson  Fox  and  Balthazar  Forster,:}:  consists  of  rest 
in  bed  and  rectal  alimentation,  with  such  nourishment  as  will  cause 
the  stomach  the  least  trouble.  As  adjuvants  we  have  moist  heat  in 
the  form  of  external  applications,  which  quiet  the  pain  [except 
when  there  is  bleeding]  and  at  the  same  time  diminish  the  irrita- 
tion ;  and,  internally,  a  course  of  hot  Carlsbad  water  or  a  solution 
of  Carlsbad  salts. 

I  could  quote  a  large  number  of  cases  either  cured  with  surpris- 
ing rapidity  and  safety  by  this  method,  or  at  least  freed  for  a  long 
time  from  all  difficulties,  but  the  following  will  suffice : 

In  October,  1888,  I  was  called  in  consultation  to  see  Mrs.  Fr.,  aged 

*  Ziemssen.    Ueber  die  Behandlung  des  Magengeschwiirs.    Volkmann's  Saraml. 
klin.  Vortrage,  No.  15. 

f  Leube.     Magenkrankheiten,  S.  117.  %  Loc.  cit.,  p.  944. 


TREATMENT  OF  GASTRIC  ULCER.  435 

thirty-seven,  a  widow  who  supported  her  children  by  working  on  the 
machine  as  seamstress.  Tyiiical  history  of  ulcer,  haematemesis,  gastralgia. 
Severe  pain  after  each  meal,  and  also  at  times  during  the  night  and 
morning  on  an  empty  stomach.  Dieted  strictly  and  lost  much  flesh. 
Appeared  pale  and  miserable.  Pain  on  pressure  in  the  epigastrium.  No 
tumor.  Abdominal  walls  soft,  strong  muscular  contraction  occurring 
only  on  making  pressure  at  the  spot  mentioned.  No  floating  kidney. 
Urine  negative. 

Patient  treated  till  the  middle  of  January,  1889,  with  internal  medica- 
tion— nitrate  of  silver,  bismuth  with  ext.  hyoscyam.  and  morphine,  tinct. 
opii,  etc. — but  without  success.  At  last,  on  January  14th,  she  applied  for 
admittance  at  the  Augusta  Hospital.  The  typical  ulcer  cure  was  insti- 
tuted, and  the  patient  was  treated  in  the  manner  soon  to  be  described. 
Her  troubles  were  rapidly  lessened,  and  then  ceased  entirely.  The  sensi- 
tiveness at  the  pit  of  the  stomach — a  point  on  which  I  always  lay  great 
stress — disappeared,  and  on  the  20th  of  February,  that  is,  after  six  weeks, 
the  patient  was  discharged  cured.  Inasmuch  as  she  was  very  foolish 
regarding  her  diet,  and  during  her  convalescence  took  more  than  was 
allowed  her,  and  as  this  propensity  was  responsible  for  a  renewed  attack 
of  gastralgia  at  about  the  middle  of  the  treatment,  we  can  really  say  that 
she  gave  us  still  stronger  proof  of  her  recovery.  She  has  also  remained 
free  from  relapses  up  to  the  time  of  her  last  report. 

However,  I  dare  not  conceal  the  fact  that  such  a  prompt  cure 
does  not  always  result,  and  that  I  have  also  had  cases  which  as  long 
as  they  were  taking  the  treatment  felt  very  well,  but  as  soon  as  they 
returned  to  their  daily  life,  even  if  with  all  precautions,  suffered 
from  fresh  attacks  and  the  return  of  the  old  difficulties.  ISTeverthe- 
less,  these  have  always  been  in  the  minority. 

Leube  emphasizes  the  fact  that  the  composition  of  the  Carlsbad 
salt  is  both  neutralizing  and,  owing  to  the  sodium  chloride  which 
it  contains,  stimulating  in  its  action ;  but  as  we  know  that  the  acid- 
ity is  increased  in  the  majority  of  cases,  the  latter  property  may 
be  regarded  more  as  a  disadvantage.  Depression  rather  than  stimu- 
lation is  indicated.  ^Neither  can  I  ascribe  very  much  importance  to 
the  neutralization  or  diminution  of  the  acidity  if  this  be  done  but 
once,  and  then  in  a  stomach  containing  no  food,  which,  unless  there 
is  continuous  secretion  (hypersecretion),  is  therefore  empty.  The 
essential  indications  seem  rather  to  be  the  reduction  of  the  hyper- 
secretion by  means  of  neutral  salts,  as  already  surmised  by  Pember- 
ton  and  directly  proved  by  Jaworski,*  and  in  the  sedative  action 

*  Jaworski.  Ueber  Wirkung,  therapeutischer  Werthe  und  Gebrauch  des  neuen 
Carisbader  Quellsalzes.    Wiener  med.  Wochenschr.,  6-16, 1886. 


436  DISEASES  OP  THE  STOMACH. 

of  large  quantities  of  warm  water ;  *  and,  finally,  in  the  laxative 
effects  of  the  neutral  salts.  If  the  action  of  the  waters  of  the 
simple  alkaline  springs  has  been  found  to  be  less  effective  than  that 
of  the  alkaline  saline,  it  is  probably  due  to  the  failure  of  supplying 
the  laxative  effects  by  other  means. 

Where  this  laxative  action  is  absent,  as  is  frequently  the  case  in 
the  Carlsbad  waters,  we  must  produce  it  by  the  addition  of  Glau- 
ber's salt,  or,  better,  by  means  of  vegetable  cathartics,  preferably 
rhubarb  or  senna  in  watery  infusion.  Moreover,  it  is  not  necessary 
for  us  to  adhere  too  narrow-mindedly  to  one  standard ;  our  watch- 
word is  necessity.  It  is  immaterial  whether  we  relieve  the  pain  by 
hot  fomentations,  or,  if  these  be  ineffectual,  by  subcutaneous  injec- 
tions of  morphine ;  whether  we  give  the  patient  a  solution  of  Spru- 
del  salt  or  the  natural  Carlsbad  spring  water,  or  that  of  an  effer- 
vescing soda  spring,  such  as  Ems,  or  Yichy,  or  jS^euenahr,  and  sup- 
ply the  laxative  action  missing  in  these  waters  by  means  of  other 
aperients.  We  give  300  to  500  c.  c.  [f  ^  x  to  Oj]  of  Carlsbad  water. 
It  is  immaterial  from  which  spring  it  comes,  because  there  are 
no  essential  differences  in  their  chemical  composition,  while  the 
differences  of  temperature  existing  in  the  waters  of  the  individual 
hot  springs  may  be  disregarded,  for  they  are  always  taken  only  as 
hot  as  the  patient  can  bear  them ;  in  other  words,  at  about  the 
same  temperature.  Of  the  salt  about  15  grammes  [one  table- 
spoonful]  are  dissolved  in  one  half  litre  [one  pint]  of  [hot]  water. 
This  is  taken  as  at  the  "cure" — i.  e.,  small  swallows  at  short  in- 
tervals. 

For  the  first  three  days  I  give  the  patients  absolutely  no  food, 
and  allow  them  only  a  nutritive  enema  three  times  daily.  Then 
feeding  by  the  mouth  is  commenced  with  small  quantities  of  milk  f 
and  gruels;  later  on  I  give  leguminous  soups,  then  leguminous 
vegetables  and  potatoes  in  the  form  of  a  puree,  to  which  small 

*  [Oser  cautions  against  giving  too  great  amounts  of  water  or  anything  producing 
large  quantities  of  gas,  on  account  of  the  danger  of  distending  the  walls  of  the 
stomach  and  thus  opening  the  ulcer.  However,  this  seems  to  be  theoretical  rather 
than  practical. — Ed.] 

f  Cruveilhier  was  the  first  to  recommend  the  milk  diet.  Gruels  cooked  with 
milk  are  preferable  to  pure  milk,  because  the  casein  coagulates  more  floeculently 
than  it  does  in  pure  milk. 


TREATMENT   OF   GASTRIC   ULCER.  437 

quantities  of  meat-brotli  are  added  later;  also  rice  [stewed], 
chestnuts,  sago,  taj^ioca,  and  the  like.  Later  on  we  may  allow  raw 
or  lightly  boiled  eggs,  meat  solution,  calves'  brain,  finely  scraped 
cold  ham,  white  breast-meat  of  game  or  tender  saddle  of  venison, 
etc.  It  is  to  be  regretted  that  milk,  the  neutralizing  action  of 
which  on  acids  is  well  known,  and  which  has  also  recently  been 
demonstrated  by  Leo  and  Yon  Pfungen,  is  so  badly  borne  by  many 
persons,  no  matter  whether  we  add  sodium  bicarbonate,  lime  water, 
whisky,  coffee,  etc.  In  a  number  of  such  cases  peptonized  milk, 
the  taste  of  which  has  been  corrected  with  sweet  cream,  can  be 
tolerated.  De  Bove*  recommends  meat  powder  to  which  an 
alkali  has  been  added.  Only  in  the  third  week  is  a  quantitatively 
and  qualitatively  ampler  diet  permitted,  but  always  with  the  view 
of  sparing  the  stomach  as  much  as  possible.  We  must  of  course 
individualize,  for  the  patients  undoubtedly  lose  flesh  on  this  diet ; 
but  they  recover  rapidly,  the  gastralgic  8,ttacks  remain  absent,  and 
now  is  the  time  to  meet  the  second  indication,  to  improve  the  gen- 
eral condition,  t 

For  this  purpose  we  use  the  iron  preparations,  either  alone  or  in 
combination  with  arsenic.  The  former  are  indicated  in  cases  of 
pure  chlorosis  or  ansemia,  the  latter  if  we  have  to  deal  with  an  en- 
feebled nervous  system  and  we  wish  to  exert  an  indirect  action 
upon  it  by  direct  stimulation  of  metabohsm.  The  scruples  formerly 
existing  against  the  use  of  iron  in  cases  of  gastric  ulcer  were  caused 
by  the  experience  that  this  drug  is  often  poorly  borne  as  long  as  an 
active  process  is  going  on  ;  but  they  are  not  justified  as  soon  as 
recovery  has  commenced  and  is  well  under  way.  I  can  at  least 
fully  concur  in  the  experiences  which  Te  Gempt  X  has  published  on 
this  subject.  He  uses  Drees's  hquor  ferri  albumin.,  which,  as  is 
well  known,  is  a  preparation  made  by  treating  albumen  with  chlo- 


*  Quoted  by  Matthieu.  Ulcere  de  Testomac.  Gaz.  des  hopital,  1892, 
No.  99. 

f  [Da  Costa  reports  three  cases  of  gastric  ulcer  which  he  treated  successfully 
with  ice  cream  ad  libitum,.  The  ice  cream  must  contain  no  corn  starch  or  other 
substances  employed  for  thickening  purposes,  and  it  must  not  be  over  twenty-four 
hours  old.     Medical  News,  August  8,  1891,  p.  155.— Ed.] 

t  Te  Gempt.  Ueber  Behandlung  des  runden  Magengeschwurs  mit  Eisenalbu- 
minat.    Berl.  klin.  Wochenschr.,  1886,  S.  240. 


438  DISEASES  OF  THE  STOMACH. 

ride  of  iron,  and  which  is  expensive.*  Inasmucli  as  all  we  care 
for  is  to  introduce  the  proper  proportions  of  albumen  and  iron  into 
the  stomach,  so  as  to  produce  an  absorbable  peptonate  of  iron, 
and  inasmuch  as  we  know  that  the  power  of  forming  peptones  is 
not  extinguished  in  ulcer  of  the  stomach,  I  prescribe  this  medica- 
ment in  a  simpler  and  less  expensive  manner.  I  order  three  times 
daily  a  teaspoonful  of  a  2  to  3  per  cent  solution  of  ferri  sesquichlor. 
(Ph.  Ger.)  [ferri  chloridum,  U.  S.  P.]  to  be  added  to  a  wineglassful 
of  egg- water  (one  part  of  white  of  egg  to  two  parts  of  water)  and 
taken  through  a  glass  tube  in  order  to  spare  the  teeth.  The  ad- 
vantages of  the  chloride  of  iron,  as  one  of  the  mildest  and  most 
easily  assimilable  preparations  of  iron,  have  been  extolled  by  many ; 
with  these  I  also  wish  to  join.  However,  it  is  well  known  that 
every  one  has  a  favorite  iron  preparation,  and  if  one  has  more  con- 
fidence in  any  other  and  gets  good  results  with  it,  its  use  ought  not 
to  be  discontinued  ;  for  success  does  not  depend  upon  the  prepara- 
tion, but  upon  its  assimilation,  and  especially  upon  its  action  on  the 
blood.  I  formerly  gave  arsenic  in  the  form  of  Fowler's  solution, 
together  with  tinct.  ferri  chlor.  According  to  Liebreich's  brilliant 
investigations,  arsenious  acid  appears  to  be  more  effective,  and  I 
prescribe  it  in  pills  containing  2  milligrammes  [gr.  -gL-]  of  arsenious 
acid  and  2  centigrammes  [gr.  i]  of  ferri  sesquichlor.  [Ph.  Ger.] 
Much  smaller  but  decidedly  efficacious  (as  shown  by  metabolic  in- 
vestigations made  by  Dronke  and  myself  f)  doses  of  iron  and 
arsenic  may  be  administered  with  the  waters  of  Levico  and  Kon- 
cegno,  which  are  usually  well  borne.:}:  It  is  advisable  to  employ  in- 
creasing doses,  and  to  give  the  drugs  after  meals.  This  regimen 
must  be  continued  for  months,  during  which  the  use  of  arsenic  is  to 
be  discontinued  for  three  to  five  days  every  three  weeks.  The 
combined  use  of  arsenic  and  iron  may  thus  be  continued  for  a  long 
time,  if  we  employ  the  caution  of  giving  the  arsenic  in  increasing 
and  then  diminishing  doses,  say  from  3  to  10  pills  (!)  a  day.  The 
diet  may  gradually  become  more  generous,  but  must  nevertheless 

*  [Dietterich's  peptonate  of  iron  and  Gude's  peptomanganate  of  iron  are  more 
common  in  this  country. — Ed.J 

t  Ewald  und  Dronke.     Berl.  Idin.  Wochenschr.,  1892,  No.  19  und  20. 

X  [The  dose  of  these  waters  is  to  begin  with  one  teaspoonful  and  increase  gradu- 
ally to  one  or  two  tablespoonfuls, — Ed.] 


TREATMENT  OF  GASTRIC   ULCER.  439 

he  strictly  regulated  for  months  ;  and  tliose  patients  wlio  tend  to 
excesses  must  be  made  to  adhere  rigidly  to  a  written  bill  of  fare 
and  a  certain  allowance  of  food. 

This  treatment  brilliantly  confirms  the  remark  of  Leube,  that 
"  the  treatment  of  gastric  ulcer  remains  a  thankful  task  to  the  phy- 
sician because  the  cures  form  by  far  the  greater  majority  of  the 
therapeutic  results,  if  we  include  those  cases  in  which  the  patients 
are  freed  from  all  difiiculties  for  a  long  time,  and  have  relapses  only 
later  on  "  ;  *  and  also,  "  I  am  convinced  that  the  more  strictly  the 
dietetic  directions  are  carried  out  at  the  bedside,  the  more  will  the 
unpleasant  medicinal  treatment  of  ulcer  of  the  stomach  dwindle 
away," 

However,  the  latter  is  nevertheless  indispensable  :  first,  because 
there  are  very  many  patients  who  are  unwilling  or  unable  to  sub- 
ject themselves  to  such  a  "  cure " ;  secondly,  because  there  are 
many  cases  which  present  urgent  symptomatic  indications  which 
must  be  met  immediately. 

Bismtith  has  enjoyed  a  very  great  reputation  ever  since  it  was 
first  recommended  by  Odier,  of  Geneva,  although  we  have  never 
been  sure  of  its  mode  of  action,  as  is  shown  by  the  great  variations 
in  its  dosage,  from  O'l  gramme  [gr.  jss.]  up  to  15  grammes  [3SS.]. 
Given  by  Odier  "  enterieurement  coTnme  antispasmodique,^^  it  was 
used  later,  for  instance  by  the  English  school,  for  the  purpose  of 
remedying  an  "  undue  secretion."  In  our  day  the  remarkable  sup- 
position is  frequently  advanced  that  the  comparatively  diminutive 
amount  of  the  jDreparation  introduced  into  the  stomach  selects  the 
surface  of  the  ulcer  on  which  to  deposit  itself  and  form  a  protective 
covering.  Since  we  give  it  chiefly  in  doses  of  O'S  gramme  [gr.  vijss.] 
together  with  5  to  10  milhgrammes  [gr,  y^^  to  I]  of  morphine,  it 
can  not  be  said  how  much  of  the  possible  action  is  to  be  ascribed  to 
the  latter.  To  me  the  French  method  appears  to  be  the  most  ra- 
tional, in  which  large  doses,  10  to  15  grammes  [3ijss.  to  §  ss.],  are 
given  suspended  in  water.  However,  on  account  of  the  expense 
this  is  a  line  of  treatment  not  applicable  to  all. 

But  bismuth  has  been  successfully  used  by  so  many  excellent 


*  Leube.    Magenkrankheiten,  S.  113. 
29 


440  DISEASES  OF  THE  STOMACH. 

practitioners,  especially  in  cases  of  gastralgia — Budd  recommends  it 
just  "  in  gastralgia  with  increased  secretion  of  the  gastric  acid " 
— that  all  possibilities  of  illusion  seem  to  be  excluded.  JTeyerthe- 
less,  the  question  whether  it  possesses  a  specific  action,  or  whether 
it  can  not  be  just  as  well  replaced  by  some  other  preparation  of  a 
poorly  soluble  alkaline  salt — e.  g.,  bicarbonate  of  calcium — must 
still  remain  undecided. 

[The  use  of  very  large  doses  of  bismuth  has  been  recommended 
by  Fleiner,*  especially  for  the  treatment  of  ambulatory  cases  of 
gastric  ulcer.  The  technique  is  as  follows  :  10-20  grammes  [  5  i— f] 
of  bismuth  subnitrate  are  suspended  in  200  c.  c.  [f  ^  vjf  ]  of  luke- 
warm water.  This  is  introduced  into  the  stomach  in  the  early 
morning  after  having  washed  out  the  viscus,  if  necessary.  Fleiner 
advises  that  the  bismuth  mixture  be  introduced  through  the  tube ; 
this  is,  however,  not  essential,  as  equally  good  results  may  be  ob- 
tained without  it.  Sixty  c.  c.  [f  ^  ij]  water  are  either  drank  or 
poured  in  through  the  tube  to  wash  down  any  of  the  bismuth  which 
may  have  adhered  in  its  passage  to  the  stomach.  The  patient  then 
lies  down  for  half  an  hour  in  the  position  in  which  the  bismuth  may 
deposit  itself  upon  the  ulcer.  Fleiner  states  that  it  takes  5  to  6  min- 
utes for  the  bismuth 'to  be  deposited  upon  the  mucous  membrane. 

The  bismuth  acts  mechanically  in  protecting  the  eroded  mucosa 
and  in  lessening  the  irritation  of  the  exposed  nerve  endings,  and  it 
also  is  an  antiseptic. 

A  special  diet  is  not  absolutely  necessary,  neither  is  the  patient 
confined  to  bed,  but  he  may  go  about  and  attend  to  his  ordinary 
duties. 

Fleiner  has  reported  excellent  results,  which  have  been  corrobo- 
rated by  Rosenheim,f  Matthes,:}:  Savelieff,*  Cramer,  |  and  others.  1 
have  been  well  satisfied  with  the  results  which  I  have  obtained  in  a 
number  of  cases  of  ulcer ;  it  has  also  been  serviceable  in  some  cases 
of  obstinate  gastralgia.     I  have  not  used  the  tube  ;  neither  have  I 

*  [Fleiner.     Verhandlung.  des  Congresses  fiir  innere  Med.,  1893. — Ed.] 
t  [Rosenheim.     Berliner  Klinik,  1894,  Heft  71,  p.  15.— Ed.] 

t  [Matthes.     Centralbl.  ftir  klin.  Med.,  1894,  No.  1.— Ed.] 

*  [Saveiieff.  Therapeut.  Monatshefte,  October,  1894,  p.  485.  This  paper  con- 
tains full  bibliography. — Ed.] 

I  Cramer.    Miinch.  med.  Wochenschr.,  June  23,  1896. — Ed.] 


TREATMENT  OP  GASTRIC    L'LCER.  441 

withdrawn  the  supernatant  fluid,  as  recommended  by  Fleiner.  It 
is  surprising  how  tenaciously  the  bismuth  adheres  to  the  mucous 
membrane ;  thus,  if  the  stomach  is  washed  30  minutes  after  15 
grammes  [  ^  ss.]  have  been  introduced,  and  the  bismuth  which  is 
obtained  in  the  wash- water  is  filtered  out,  but  I"- 5  to  2  grammes  [gr. 
xvij-xxx]  can  be  obtained. 

If  good  prej)arations  of  bismuth  are  used,  no  poisonous  effects 
will  be  observed.  My  results  agree  with  all  those  which  have  thus 
far  been  reported  in  the  absence  of  all  toxic  effects.  In  several 
cases  in  which  I  have  given  15  grammes  [  §  ss.]  daily  for  several 
weeks,  no  bad  effects  were  observed  from  these  large  doses.  Keither 
need  there  be  any  fear  of  enteroliths  from  these  large  doses.  Con- 
stipation is  sometimes  observed ;  if  it  occur,  large  oil  enemata  will 
relieve  it.  In  some  cases  I  have  even  observed  diarrhoea.  Saveheff 
also  noted  the  absence  of  constipation,  and  states  that  it  disappeared, 
if  present,  during  the  treatment. 

The  treatment  is  not  to  be  employed  in  acute  cases,  but  is  to  be 
reserved  for  the  subacute  or  chronic  forms.] 

Ord  *  very  highly  recommends  potassium  iodide  combined  with 
sodium  bicarbonate  for  the  catarrh  which  accompanies  gastric  ulcer. 
It  may  be  used  thus : 

]^   Potass,  iodidi 2-0  [gr.  xxx] 

Sodii  bicarbonatis 5-0  [gr.  Ixxv] 

Acid,  hydrocyan.  dil gtt.  iij 

Inf.  rad.  gentian 3-0  :  150-0  [gr.  xlv :  f  3  v] 

M.     Sig. :  One  tablespoonful  three  times  daily. 

What  I  have  said  of  bismuth  will  almost  apply  to  nitrate  of 
silver.  Here,  too,  we  are  entirely  in  the  dark  as  to  its  mode  of 
action,  for,  as  Leube  has  said,  we  can  scarcely  believe  in  a  direct 
local  action  of  the  small  doses— O'Ol  gramme  [gr.  |]— of  nitrate  of 
silver,  and  it  is  no  more  possible  that  any  effective  combination 
with  an  acid  can  be  formed  by  it.  N'otwithstanding  this,  we  also 
have  weighty  evidence  (I  will  only  mention  Gerhardt)  in  favor  of 
the  effectiveness  of  the  drug.  In  a  few  cases  I  have  obtained  de- 
cided but  also  only  transient  relief  of  the  difficulties  with  a  solution 


*  W.  Ord.     Gastric  Ulcer.     American  Jour.  Med.  Sciences,  June,  1889. 


442  DISEASES  OF   THE  STOMACH. 

of  0'2  [gr.  iij]  argent,  nitrat.  in  150  [f  5  v]  of  water,  taken  every 
two  hours ;  while  in  other  cases  I  had  to  discontinue  the  drug  after 
it  had  been  used  a  few  times,  because  increased  discomfort  in  the 
stomach,  nausea,  anorexia,  coated  tongue,  and  also  constipation  ap- 
peared. On  the  other  hand,  in  one  of  my  cases  I  had  to  discard  it 
because  just  the  reverse  occurred — namely,  watery  evacuations 
always  followed  almost  immediately  after  taking  it.  [Boas  *  praises 
nitrate  of  silver  very  highly,  especially  in  mild  cases  or  in  patients 
who  can  not  undertake  a  rest  cure.  He  begins  with  gr.  iv  to  f  5  iv 
of  water  ( ^  ss.  t.i.d.),  and  gradually  increases  it  to  gr.  vj  to  f  §  iv  of 
water.] 

[Kankin  f  has  reported  ten  cases  in  which  good  results  were  ob- 
tained from  a  combination  of  pepsin,  iron,  and  cannabis  indica,  given 
combined  in  pill  form.  On  the  other  hand,  Grote  X  has  recently 
pubhshed  the  results  of  his  experiments  with  papain ;  he  found  that 
this  substance  was  not  well  borne,  and  increased  the  pain  in  hyper- 
acidity and  ulcerative  processes  in  the  stomach.] 

In  my  opinion,  the  dietetic  principles  given  above  are  also  the 
most  serviceable  in  the  treatment  of  ambulatory  cases,  and  we  must 
endeavor  to  carry  them  out,  at  least  as  far  as  the  diet  is  concerned, 
as  fully  as  possible.  Here  we  must  give  special  consideration  to 
milk.  Moreover,  I  try  to  blunt  the  hyperacid  gastric  juice  by  the 
hourly  exhibition  of  small  doses  of  an  alkali  combined  with  rhu- 
barb and  cane  or  milk  sugar.  The  rhubarb  acts  mildly  on  the 
bowels,  while  the  sugar  has  a  decided  anodyne  action,  on  account  of 
which  it  has  frequently  been  recommended.  I  have  seen  fairly 
good  results  from  the  following  powder  : 
]^  Magnesise  ustge, 
Sodii  carbonatis, 

Potass,  carbonatis aa    5*0  [  3  j  gr.  xv] 

Pulv.  rad.  rhei lO'O  [  3  ijss.] 

Sacch.  lactis 25*0  [  3  vj  gr.  xv] 

M.     Sig. :  A  large  pinch,  dry  on  the  tongue,  every  hour. 
Morphine,  either  by  the  mouth  or  subcutaneously,  stands  first 

*  [Boas.     Op.  cit.,  p.  60.— Ed.] 

+  [Rankin.     Lancet,  February  9,  1895.— Ed.] 

t  [Grote.     Deutsch.  med.  Wochenschr.,  July  23,  1896,  p.  474.— Ed.] 


TREATMENT   OP  GASTRIC   ULCER.  443 

for  the  relief  of  severe  gastralgia.  Solutions  of  chloroform  (1 :  120, 
5  ss.  every  tvt^o  hours)  have  at  times  an  excellent  effect,  not  only  on 
the  temporary  pain,  but  altogether  on  the  course  of  the  process. 
[Stepp  *  highly  recommends  the  use  of 

]^    Chloroformi  purificati 1-0  [ttixv] 

Bismuth,  subnitratis 3'0  [gr.  xlv] 

Aquffi 150-0  [f  5  v] 

M.  Sig.  :  Tablespoonful,  well  diluted,  every  hour.] 
Among  the  remaining  anodynes  I  have  frequently  used  lupulin, 
ext.  cannabis  indie,  ext.  hyoscyam.,  and  belladonna  experimentally, 
but  I  have  always  been  obliged  to  return  to  morphine.  I  have  been 
especially  dissatisfied  with  cannabis  indica,  which  has  been  so  highly 
lauded  by  Germain  See  ;  not  alone  did  1  repeatedly  fail  to  obtain 
any  analgesic  or  quieting  effects,  but,  on  the  contrary,  unpleasant  con- 
ditions of  excitement  [see  page  244].  I  have  no  personal  experi- 
ence with  strontium  bromide,  which  has  been  highly  praised  by  the 
same  writer  for  its  good  effects  in  hyperchlorhydria.f  [Atropine 
has  also  been  recommended  for  the  latter  purpose  ;  it  may  be  given 
in  doses  of  gr.  -^  three  times  daily.]  ^ 

Formerly  leeches  were  frequently  applied  over  the  affected  site  ; 
blisters  and  even  the  cautery  were  used.  Ice-bags  will  suffice,  or 
ice-cold  or  warm  applications,  or  Leiter's  coil,  which,  where  circum- 
stances allow  it,  is  the  cleanest  and  most  comfortable  way  of  apply- 
ing cold. 

Nothing  is  more  serviceable  in  vomiting  than  a  carefully  regu- 
lated diet.  We  may  allow  the  patients  to  drink  large  quantities  of 
warm  water  several  times  during  the  day,  and  also  give  them  pieces 
of  ice  with  chloroform ;  but  as  the  vomiting  usually  ceases  with 
the  gastralgia,  it  is  met  by  the  treatment  of  the  latter. 

Special  care  is  required  in  hcBmatemesis,  not  only,  as  is  self- 
evident,  when  it  is  profuse,  but  also  when  the  haemorrhages  are 
smaller.  The  first  indication  under  all  circumstances  is  absolute 
physical  and  mental  rest,  and  the  avoidance  of  all  internal  and  ex- 


*  [Stepp.     Therapeut.  Monatshefte,  November,  1893,  p.  540.— Ed.] 
f  Gr.  See.     Sur  Taction  du  bromure  de  strontium  dans  les  affections  de  I'estomac. 
Bullet,  de  I'Acad.  frang.,  1891,  No.  42. 

X  [Therapeut.  Monatshefte,  1895,  p.  384.— Ed.] 


444  DISEASES  OF  THE  STOMACH, 

ternal  irritation  ^  to  the  stomacli.  Even  in  tlie  smaller  hsemor- 
rhages,  since  they  frequently  are  precursors  of  larger  ones,  the  pa- 
tients, if  circumstances  will  permit,  ought  to  subject  themselves  to 
this  regimen  for  several  days,  and  the  entire  plan  of  treatment 
should  be  carried  out.  We  may  give  small  pieces  of  ice,  or  table- 
spoonfuls  of  ice-cold  tea  or  ice-cold  fiaid  peptone  solutions.  In  the 
cases  in  which  it  is  not  known  whether  the  patients  take  milk  well, 
I  do  not  give  it,  but  instead  I  prescribe  for  the  first  day  a  solution 
of  grape  sugar,  which  is  replaced  by  some  bouillon  made  of  meat- 
peptones  taken  very  cold,  or  cold  thin  gruels  made  of  barley  or  oat- 
meal. Where  it  is  possible,  I  order  nutritive  enemata,  which  must 
be  given  with  care.  Several  times  during  the  day  I  inject  one  or 
two  syringef uls  *  of  the  following  into  the  region  of  the  stomach : 
9^   Ext.  secalis  cornuti  [Ph.  Ger.].  . .   2*5  [gr.  xxxvij] 

Glycerini, 

Aquae aa  5-0  [f  3  j  ttixv].     M. 

[See  page  369.]  However,  I  must  add  that  in  some  persons  ergo- 
tin  causes  very  unpleasant  symptoms  of  oppression  and  dizziness. 
I  have  never  been  able  to  convince  myself  of  the  reliability  of  the 
fluid  extracts  of  hydrastis  canadensis  or  hamamelis  virginica.  In  case 
the  patients  are  much  excited,  morphine  may  be  added  to  this  in- 
jection. As  a  rule,  the  haemorrhages,  unless  they  come  from  too 
large  a  vessel,  are  controlled  by  this.  Formerly,  remedies  which 
have  the  reputation  of  being  styptics,  like  acetate  of  lead,  chloride 
of  iron,  and  oil  of  turpentine,  were  given  internally ;  but  we  do  not 
use  them  now,  since  we  have  a  much  more  effective  and  rational 
remedy  in  ergot. 

In  two  of  my  cases,  haemorrhages  which  recurred  repeatedly  "for 
several  days  in  spite  of  the  means  above  mentioned  were  checked 
with  washing  out  the  stomach  with  ice  water.  After  preliminary 
cocainization  of  the  fauces  and  a  small  hypodermic  injection  of  mor- 
phine, the  soft  tube  was  carefully  introduced  and  the  stomach  was 
washed  out  a  number  of  times  with  ice  water,  when  the  haemor- 
rhage at  once  ceased.  In  one  of  these  cases  this  was  successfully 
repeated  three  times  in  the  course  of  a  few  weeks ;  in  the  second 

*  [Pravaz  syringe  ;  holds  one  gramme. — Ed.] 


TREATMENT   OF   GASTRIC   ULCER.  445 

and  third  hcemorrhages  this  treatment  was  at  once  applied.  [This 
treatment  has  also  been  highly  praised  by  Minkowski.  Operations 
have  also  been  performed  on  account  of  hsemorrhage  from  the  stom- 
ach. This  was  first  done  by  Mikulicz,*  without  success,  however. 
Subsequeiitly  Kiister  f  was  successful  in  two  cases.] 

As  most  of  the  blood  passes  on  into  the  intestines  and  decom- 
poses there,  irritation  may  be  caused  there ;  hence,  if  there  are  no 
spontaneous  stools,  mild  aperients,  preferably  rhubarb  with  sulphur, 
should  be  given. 

Should  symptoms  of  collapse  appear,  we  may  give  hypodermic 
injections  of  camphor  and  ether  (1  :  6),  or  enemata  of  wine  or  wine 
and  egg  or  peptone,  and  also  hot  applications  to  the  extremities. 
In  threatened  death  from  hsemorrhage,  with  very  small  pulse, 
anaemic  murmurs  heard  over  the  heart,  and  cerebral  anaemia,  we 
proceed  to  transfusion  of  blood  or  infusion  of  salt  solution.  The 
advantages  of  these  two  methods  have  been  extensively  discussed, 
but  they  have  not  yet  been  finally  decided,  although  lately  there  is 
an  increase  in  the  number  of  cases  successfully  treated  by  salt  infu- 
sion.:]:  The  best  method  is  subcutaneous  infusion  with  a  large  can- 
nula [which  is  attached  to  the  tube  of  an  ordinary  fountain  syringe]. 
The  salt  solution  [0-4  to  0-6  per  cent]  is  heated  to  the  temperature 
of  the  body  and  is  allowed  to  run  in  simultaneously  through  two 
cannulas  ;  gentle  massage  being  employed,  a  litre  of  water  can  be 
infused  in  a  short  time.  I  prefer  the  subclavicular  region  as  the 
site  of  the  infusion.  In  favorable  cases  the  blood  regenerates  quite 
rapidly.  In  a  twenty -five-year-old  patient  I  found  the  number  of 
red  cells  to  be  2,100,000  on  the  day  after  the  infusion  ;  two  weeks 
later  it  was  3,560,000,  with  a  slight  leucocytosis. 

Peritonitis  due  to  perforation  demands  the  exhibition  of  large 
doses  of  opium,  best  given  in  suppositories  or  enemata,  and  also  the 


*  [Mikulicz.  Verhandlungen  d.  deutsch.  Gesellsch.  f.  Chir.,  1887,  p.  337.— Ed.] 
t  [Kuster.  Ibid..  1894 ;  Centralbl.  f.  Chir..  1894,  No.  51.— Ed.] 
t  For  instance,  Michaelis,  Heftige  Magenblntung  nach  einer  Magenausspiilung 
(wahrscheinlich  bei  Ulcus).  Ertolgreiche  Kochsalztransfusion.  Berl.  klin.  Woch- 
enschr.,  1884,  No.  25. — I  myself  have  seen  three  cases  of  subcutaneous  salt-water 
infusion,  in  all  of  which  the  hematemesis  had  lasted  till  the  patient  was  pulseless. 
All  three  women,  aged  twenty-six,  nineteen,  and  twenty-three  years,  respectively, 
recovered  quite  rapidly. 


44:6  DISEASES  OP  THE  STOMACH. 

use  of  ice-cold  applications  to  the  abdomen.  If  doubt  exists  whether 
the  stomach  be  full,  an  attempt  may  be  made  to  empty  it  by  means 
of  the  stomach  tube,  after  the  patient  has  as  far  as  possible  been 
rendered  incapable  of  reaction  by  means  of  a  large  dose  of  mor- 
phine or  by  the  local  application  of  cocaine.  But  under  all  circum- 
stances we  must  prevent  every  attempt  at  gagging  and  choking, 
since  this  may  lead  to  the  enlargement  of  the  perforation.  At 
times  this  treatment  has  succeeded  in  keeping  the  peritonitis  local- 
ized and  causing  adhesions.* 

Laparotomy  has  been  proposed  for  the  cases  of  perforations,  and 
a  successful  one  has  been  reported  by  Parsons. f 

[Eecently  many  operations  have  been  reported,  especially  by 
English  surgeons,  in  cases  of  acute  perforation  of  gastric  ulcers.  In 
an  excellent  paper.  Weir  and  Foote :}:  have  collected  and  analyzed 
78  cases  of  laparotomy  performed  for  this  purpose,  and  also  9  lapa- 
rotomies for  acute  perforation  of  duodenal  ulcers.  The  average 
mortality  was  Yl  per  cent ;  great  differences,  however,  were  found, 
according  to  the  time  which  had  elapsed  between  perforation  and 
operation.  Thus  the  mortality  of  23  cases  operated  within  twelve 
hours  was  only  39  per  cent;  while  in  17  cases  operated  within 
twelve  to  twenty -four  hours  it  was  Y6  per  cent ;  and  in  32  cases 
operated  after  twenty-four  hours  it  was  87  per  cent. 

Successful  excisions  of  ulcers  have  also  been  reported  by  Czerny, 
Cordua,  Keen,  Lange,  and  others.*] 

Finally,  I  wish  to  add  my  views  of  the  treatment  at  the  mineixil 
sjprings. 

For  years  the  hot  Glauber  salt  springs,  especially  those  in  Carls- 
bad, have  enjoyed  the  established  and  undeniable  reputation  that 
the  treatment  of  ulcer  there  is  crowned  by  excellent  results.  We 
can  not  assert,  as  we  can  in  other  affections  and  concerning  other 


*  Such  cases,  which  were  verified  by  the  subsequent  perforation  of  a  second  ulcer 
and  post-mortem  examination,  have  been  reported,  for  instance,  by  Hughes,  Hilton, 
and  Ray,  Guy's  Hosp.  Rep.,  vol.  iv,  and  by  Bennett.  Clinical  Medicine,  p.  487. — 
[See  page  415. — Ed.] 

f  Parsons.     Dublin  Med.  Jour..  July,  1892. 

X  [Weir  and  Foote.  Medical  News,  April  25,  1896,  contains  full  bibliography. 
See  also  Barling,     Brit.  Med.  Journal,  June  15,  189f5. — Ed.] 

*  [Weir  and  Foote.    hoc.  ciU,  May  2,  1895,  p.  489.— Ed.] 


TREATMENT  OP  GASTRIC   ULCER.  447 

places,  that  these  results  would  have  appeared  in  spite  of  Carlsbad ; 
nevertheless,  it  is  my  opinion  that  the  same  or  perhaps  more  rapid 
effects  would  have  been  obtained  in  those  cases  had  thej  taken  the 
rest  cure  at  home,  and  if  after  its  completion  they  had  sojourned  in 
an  invigorating  climate  under  a  tonic  regimen.  For  the  adjuncts 
of  the  medicinal  springs — pure  air,  diversion,  and  beautiful  scenery 
— which  are  frequently  so  effectual,  are  not  requisite  in  the  treat- 
ment of  gastric  ulcer.  Rest  and  effective  local  treatment  are  the 
things  needed,  and  these  can  be  had  much  better  at  home  than  any- 
where else.  There  is  always  time,  after  the  disturbances  of  the 
digestive  apjDaratus  have  been  quelled,  for  the  patients  to  seek  gen- 
eral strengthening  and  invigoration  by  a  stay  at  Franzensbad,  El- 
ster,  Rippoldsau,  Pyrmont,  etc.,  in  the  mountains,  or  at  the  sea- 
shore, but  always  with  the  proviso  that  they  are  able  to  procure 
suitable  food,  preferably  by  having  the  family  cook  its  own  meals, 
In  this  regard  the  places  along  the  Baltic  are  to  be  recommended, 
as  all  opportunities  for  keeping  one's  o^\ti  house  are  there  offered. 
But  very  many  patients  much  prefer  to  go  to  the  baths  or  springs 
than  to  lie  in  bed  at  home,  and  many,  too,  can  devote  only  from  four 
to  six  weeks  to  the  treatment ;  for  these  Carlsbad  is  the  best  place, 
if  for  no  other  reason  than  that  opportunities  for  dietetic  errors  are 
practically  excluded  there.  After  Carlsbad,  N^euenahr,  Ems,  Franz- 
ensbad, and  Homburg  can  be  recommended. 


CHAPTEK  IX. 

THE    NEUROSES    OF    THE    STOMACH. — THE    PHYSIOLOGICAL   RELATIONS 
OF   THE    STOMACH. 

Before  entering  npon  tlie  many-sided  and  uncertain  province 
of  the  nervous  disorders  of  the  stomach,  I  desire  to  preface  the 
little  which  we  positively  know  of  the  innervation  of  the  stomach. 

My  brother,  Dr.  E.  Ewald,  Professor  of  Physiology  at  Stras- 
burg,  has  written  the  following  chapter  at  my  request,  and  for  this 
I  desire  to  give  him  my  heartiest  thanks.* 

THE    INNERVATION    OF    THE    STOMACH. 

It  was  an  epoch-making  advance  when  the  old  vital  forces  were 
dethroned  and  only  physical  (and  also  using  it  in  its  broadest  sense, 
chemical)  manifestations  were  allowed  to  explain  the  operations  of 
the  organism.  The  physical  methods  of  research  were  adopted  and 
the  vital  processes  were  placed  on  a  corresponding  basis.  This  was 
the  first  step  which  absolved  physiology  from  its  long  bondage  as  a 
subordinate  part  of  anatomy  and  elevated  it  to  an  independent 
science.  But  the  fond  hopes  which  were  placed  on  purely  physical 
explanations  even  up  to  a  few  decades  ago  have  since  been  proved 
to  be  unattainable,  and  the  inevitable  reaction  has  set  in  after  we 
had  in  vain  waited  for  the  solution  of  all  problems  by  physical  sci- 
ence. ISTot  that  there  was  a  reaction  to  the  old  vital  forces ;  not 
that  every  attempt  at  an  explanation  was  rejected  in  despair ;  but 
experimenters  beeame  convinced  that  in  many,  in  fact  in  nearly  all 
the  better  known  phenomena  the  physical  laws  did  not  suffice  to 
give  a  clear  explanation  of  the  mysterious  vital  phenomena.     Un- 

*  [The  form  in  which  the  following  chapter  is  presented  precludes  any  attempts 
at  revision.  Instead,  I  would  refer  the  reader  to  the  last  edition  of  Foster's 
Physiology. — Ed.] 

448 


RELATIONS  OF  THE  STOMACH  TO  THE  NERVOUS  SYSTEM.    449 

fortunately,  we  are  now  nearly  everywhere  compelled  to  assume  a 
specific  yet  absolutely  unknown  activity  of  the  living  cell.  Tins 
reaction  was  very  beneficial ;  it  unmasked  an  apparent  knowledge, 
and  brought  us  nearer  to  a  true  understanding  of  JSTature  ;  and  even 
if  we  must  finally  admit  a  mechanical  basis,  yet  we  are  still  infinitely 
remote  from  the  goal  of  all  natural  science.  That  we  can  only  reach 
this  goal  by  extending  our  knowledge  of  the  vital  phenomena  in  the 
individual  cells,  is  the  advance  which  has  resulted  from  the  reaction 
against  purely  physical  speculations.  The  same  conceptions  which 
elevated  physiology  to  an  independent  science  would  merely  have 
converted  it  into  physics  and  chemistry  as  applied  to  vital  phenom- 
ena. I^ow,  however,  its  character  as  an  independent  science  is  for- 
ever preserved. 

While,  on  the  one  hand,  the  activity  of  the  cells  can  be  more 
and  more  distinctly  differentiated  from  the  processes  which  we  have 
heretofore  considered  physical,  on  the  other  hand  we  are  compelled 
to  accord  to  the  phenomena  of  cell  life  an  always  greater  autonomy 
— i.  e.,  independence  of  the  nervous  system.  The  nerves  regulate 
the  cellular  activity,  and  cause  them  to  act  at  the  right  time  and 
with  the  proper  energy ;  but  in  many  cases  this  regulation  may  be 
absent  without  stopping  the  true  activity  of  the  cells. 

,  I  shall  now  endeavor  to  show  how  far  these  peculiarities  and 
independence  of  the  cellular  phenomenon  are  concerned  in  the  in- 
nervation of  the  stomach. 

The  General  Relations  of  the  Functions  of  the  Stomach  and  the 
Nervous  System. — The  functions  of  the  stomach  consist  mainly  of 
secretion,  absorption,  and  motion.  It  was  once  thought  that  the 
activity  of  the  glands  could  be  explained  by  the  purely  mechanical 
processes  of  filtration  and  diffusion.  The  chemical  and  physical 
changes  in  the  blood  circulating  about  the  glands,  of  which  the 
physical  were  regulated  by  the  nerves,  seemed  sufficient  to  explain 
why  the  secretion  of  one  and  the  same  gland  may  vary  in  strength 
and  composition. 

Although  Johannes  Mliller  had  long  ago  called  attention  to  the 
specific  activity  of  the  glandular  cells,  yet  only  recently  was  it  posi- 
tively demonstrated  that  the  mechanical  processes  of  filtration  and 
diffusion  do  not  suffice  to  explain  secretion,  and  that  we  must  accept 


450  DISEASES  OP  THE  STOMACH. 

the  existence  of  a  peculiar  activity  of  the  cells.*  l^erves  may  regu- 
late this  cellular  activity,  yet  secretion  is  unquestionably  possible 
without  them,  and  in  this  respect  the  animal  tissues  do  not  differ 
from  the  vegetable,  which  have  glands  but  no  nerves. 

In  the  process  of  absorption  the  specific  activity  of  the  indi- 
vidual cell  becomes  even  more  obvious.  Here,  contrary  to  physical 
laws,  some  substances  are  taken  up  while  others  are  rejected.  The 
lymph  cells  have  been  observed  to  wander  to  the  surface  of  the  in- 
testinal mucous  membrane  and  there  incorporate  drops  of  fat ;  they 
then  creep  back  even  into  the  lacteals,  where  they  give  up  these 
particles  of  fat.  In  the  face  of  such  occurrences  we  must  naturally 
avoid  physical  explanations,  since  at  all  events  they  show  that  in 
the  processes  of  absorption  peculiar  functions  of  the  living  cells 
must  coexist  with  filtration  and  diffusion. 

The  conditions  are  no  more  favorable  in  the  motor  function.  I 
disregard  entirely  the  fact  that  what  occurs  in  a  muscle  during  con- 
traction is  as  incomprehensible  as  what  constitutes  innervation  in  a 
nerve.  But  the  dependence  of  the  contraction  upon  the  nervous 
impulse,  and  the  invariable  result  of  this  impulse,  namely — a  shorten- 
ing of  the  muscle — were  formerly  regarded  as  a  general  and,  in  a 
certain  sense,  physical  law.  Indeed,  for  striped  muscle  it  would  be 
difficult  to  find  an  exception  to  this  law,  if  we  do  not  include  the 
direct  stimulation  of  the  muscle,  which  can  only  occur  in  an  ab- 
normal way.  The  striped  muscle  fiber  is  always  at  rest  till  an 
impulse  reaches  it  through  its  nerve  ;  the  result  of  this  impulse  is  al- 
ways a  contraction,  be  it  a  jerk  or  tetanus.  The  apparent  exception 
that  the  heart  continues  to  beat  even  after  all  its  nerves  have  been 
divided,  was  explained  by  assuming  that  the  impulses  may  arise  in 
the  heart  itself  in  its  ganglion  cells,  and  that  these  impulses  are 
transmitted  to  the  cardiac  muscle  fibers  through  the  intracardiac 
nerves.  It  was,  however,  discovered  that  sections  of  the  heart 
which  positively  contained  no  ganglion  cells  continued  to  beat  rhyth- 
mically. The  greatest  difficulty  of  maintaining  the  law  of  the  de- 
pendence of  muscular  contraction  upon  nervous  impulses  is  en- 
countered in  the  unstriated  muscles.     Here  we  not  alone  observe 

*  Ewald.     Klinik,  etc.,  I.  Theil,  3te  Auflage,  S.  61  und  208  et  seq. 


ANATOMY  OF  THE  GASTRIC  NERVES.  45I 

movements  which  are  independent  of  any  nervous  influence,  as,  for 
example,  in  the  ureter,  but  we  are  not  even  able  in  every  instance 
to  prove  that  the  result  of  the  nervous  impulse  is  a  contraction  of  the 
muscle.  Thus  irritation  of  the  vaso-dilator  nerves  causes  the  arte- 
rioles to  relax,  and  as  for  many  reasons  we  can  not  explain  this  by 
the  longitudinal  fibers,  we  are  compelled  to  assume  the  paradox  that 
the  circular  fibers  lengthen  upon  irritation.  We  must  therefore 
admit  that,  with  the  possible  exception  of  the  striated  muscles,  the 
above  law  does  not  always  operate,  and  that  consequently  the  mus- 
cles may  both  make  spontaneous  movements,  and  may  also  lengthen 
upon  stimulation. 

These  preliminary  remarks  will  enable  us  to  comprehend  more 
readily  the  unpleasant  fact  that  we  know  very  little  about  the  secre- 
tion, absorption,  and  motility  of  the  stomach.  The  experiments  are 
very  frequently  contradictory ;  many  contain  conditions  which,  upon 
closer  examination,  preclude  a  uniform  result.*  It  is  evident  that 
the  study  of  the  organ  has  been  undertaken  with  too  many  physical 
propositions,  whereas  here,  as  in  the  entire  digestive  tract,  biological 
laws  are  more  important.  It  seems  that  the  more  highly  vegetative 
the  functions  of  an  organ  are,  the  more  does  its  activity  depend 
upon  its  own  cells  and  the  less  upon  the  nervous  system.  In  fact, 
could  we  remove  every  nervous  element,  nerve  fibers  as  well  as  gan- 
glia, from  the  walls  of  the  stomach  without  injuring  the  other  tissues, 
it  would  still  secrete,  absorb,  and  contract  quite  well.  One  may  ask, 
Why,  then,  all  these  nerve  fibers  which  enter  the  stomach  ?  For 
the  same  reason  that  nerves  go  to  the  automatic  heart — to  connect 
it  with  the  rest  of  the  body.  On  the  one  hand,  the  stomach  has 
these  connections  with  the  central  nervous  system  to  fulfill  the  de- 
mands of  the  other  parts  of  the  body ;  and,  on  the  other,  to  enable 
the  entire  organism  to  take  cognizance  of  its  condition. 

Anatomy  of  the  Nerves  of  the  Stomach. — The  Yag%is  Nerve. — 
Below  the  neck  both  pneumogastrics  travel  along  the  oesophagus, 
the  left  or  the  smaller  being  on  its  anterior  aspect,  the  right  or  the 


*  Among  such  conditions  we  may  include,  for  example,  the  destruction  of  sec- 
tions of  the  central  nervous  system  when  we  obtain  negative  results  before  complete 
recovery  of  the  animals.  The  same  applies  to  all  electrical  stimulations  which 
can  not  be  confirmed  by  mechanical  irritation,  etc. 


452  DISEASES  OF  THE  STOMACH. 

larger  on  its  posterior ;  they  maintain  the  same  relation  in  passing 
through  the  diaphragm.  But  these  are  not  the  only  fibers  of  the 
vagi  which  reach  the  stomach,  for  as  soon  as  the  nerves  reach  the 
oesophagus  they  give  off  numerous  small  filaments  which  form  a 
delicate  plexus,  invisible  to  [the  naked  eye  of]  experimenters,  in  the 
sabstance  of  the  oesophagus  and  thus  reach  the  stomach.  Hence  it 
will  not  suffice  to  simply  divide  the  two  vagi  upon  the  oesophagus 
to  sever  their  connection  with  the  stomach  (Brachet),  but  a  circular 
incision  must  be  made  down  to  the  muscular  layer  in  the  oesophagus 
just  below  the  diaphragm  (Schiff).  The  left  nerve  passes  from  the 
anterior  surface  of  the  cesophagus  to  the  cardia  and  lesser  curvature, 
forms  the  anterior  gastric  plexus,  and  divides  into  terminal  fila- 
ments, which  proceed  along  the  anterior  surface  of  the  stomach  as 
far  as  the  pylorus,  and  form  many  anastomoses  with  the  sympa- 
thetic. Two  thirds  of  the  right  nerve  pass  to  the  abdominal  organs, 
and  only  one  tliird  reaches  the  posterior  surface  of  the  stomach, 
where  it  forms  the  posterior  gastric  plexus.  The  terminal  filaments 
radiate  from  this  over  the  posterior  surface,  and,  like  those  of  the 
left  nerve,  form  numerous  anastomoses  with  the  sympathetic. 

The  Sympathetic  Nerves. — From  the  coeliac  plexus,  the  cerebrum 
abdominale  of  the  ancients,  in  the  formation  of  which  the  vagi, 
especially  the  right,  participate,  is  developed  a  series  of  secondary 
plexuses.  Among  these  is  the  coronary  plexus  (plexus  coronarius 
ventriculi  azygos),  which  accompanies  the  left  coronary  [gastric] 
artery  of  the  stomach  to  the  lesser  curvature,  and  communicates 
with  the  two  plexuses  of  the  vagi.  Another  secondary  azygos 
plexus  is  the  hepatic,  which  is  also  partially  formed  by  the  pneumo- 
gastrics ;  a  branch  of  this  plexus  accompanies  the  right  coronary 
[pyloric]  artery  of  the  stomach  to  the  lesser  curvature,  where  it 
communicates  with  the  coronary  plexus.  Another  somewhat  larger 
branch  of  the  same  plexus,  which  has  received  the  name  of  inferior 
coronary  plexus  (plexus  coronarius  ventriculi  inferior),  passes  along 
with  the  right  gastro-epiploic  artery  to  the  greater  curvature  ;  com- 
municating branches  to  the  plexus  of  the  vagi  are  also  given  off  by 
this  plexus. 

Ganglion  Cells. — The  radicles  of  the  two  intestinal  plexuses  may 
he  trace-i  into  tlie  stomach  ;  beginning  at  the  lesser  curvature,  the 


SECRETION  OP  THE  STOMACH.  453 

plexus  myentericus  lias  already  develoi^ed  into  a  thick  network  at 
the  pylorus,  and  communicates  liere  witli  tlie  gastric  branches  of 
the  vagi  (Auerbach).  The  plexus  submucosus  (Meissners)  may  also 
be  demonstrated  even  at  the  pylorus  ;  it  probably  contains  fewer 
ganglion  cells  than  Auerbach's  plexus,  just  as  is  the  case  in  the 
other  parts  of  the  intestines. 

Secretion. — In  spite  of  numerous  and  careful  experiments  in 
stimulating  and  dividing  the  nerves  communicating  with  the  stom- 
ach, no  definite  effects  on  the  secretion  have  yet  been  produced. 
"We  might  even  doubt  the  influence  of  these  nerves  on  the  secre- 
tion, did  we  not  know  from  other  sources  that  both  stimulating  and 
depressing  impulses  pass  along  them  to  the  glands  of  the  stomach. 
The  most  important  observation  on  this  subject  was  made  by  Richet 
on  a  man  with  a  stricture  of  the  oesophagus,  which  necessitated  the 
making  of  a  gastric  fistula.  It  was  positively  proved  that  the  oesoph- 
agus was  completely  occluded,  and  that  not  the  smallest  trace  of 
saliva  could  reach  the  stomach.  On  asking  the  patient  to  chew 
some  ferrocyanide  of  potassium,  not  a  trace  of  the  salt  could  be  de- 
tected in  the  stomach  ;  yet  whenever  he  chewed  substances  with  a 
strong  taste  (sugar,  slices  of  lemon,  etc.)  there  was  always  a  copious 
secretion  in  the  stomach.  This  interesting  case  proves  that  the 
secretion  of  the  stomach  may  be  reflexly  stimulated  by  centers  lying 
outside  of  that  viscus ;  *  hence,  the  glands  of  the  stomach  are  inner- 
vated by  the  nerves  communicating  with  it.  Like  the  nerves  of 
taste,  the  olfactory  nerves  may  also  produce  this  reflex  directly — 
i.  e.,  without  the  intervention  of  a  psychical  process.  It  is  different 
when  the  reflex  proceeds  from  the  optic  nerve  ;  thus,  the  mere  sight 
of  meat  causes  a  coj)ious  secretion  of  gastric  juice  in  hungry  dogs, 
just  as  the  saliva  runs  freely  from  their  mouths  if  they  look  for  a 
long  time  at  a  lump  of  sugar.  However,  it  is  evident  that  the  reflex 
does  not  proceed  directly  from  the  optic  nerve,  but  that  the  sight  of 
the  food  flrst  produces  a  mental  impression,  and  this  it  is  which 
causes  the  secretion.  "We  ourselves  all  know  that  we  need  not  even 
see  food,  but  that  simply  the  thought  of  savory  dishes  "  makes  our 


*  Jiirgens  states  that  this  reflex  from  the  mouth  disappears  completely  after 
division  of  the  vagi  below  the  diaphragm. 


454  DISEASES  OF  THE  STOMACH, 

mouths  water."  It  will  not  be  erroneous  to  infer  that  this  reflex 
extends  also  to  the  stomach. 

The  secretion  of  the  stomach  may  be  reflexly  lessened  in  the 
same  way  that  it  may  be  stimulated.  The  taste,  smell,  sight,  and 
even  thought  of  disgusting  food  cause  such  inhibitions.  Usually 
these  various  reflexes,  whether  stimulating  or  depressing,  combine 
and  produce  a  more  marked  effect. 

Having  thus  seen  the  effects  of  visual  impressions  upon  the 
gastric  secretion,  it  becomes  evident  that  it  may  also  be  influenced 
by  psychical  processes  ;  yet  this  connection  becomes  more  apparent 
when  we  consider  the  effects  produced.  Taken  all  in  all,  their  action 
is  inhibitory ;  the  most  potent  of  all  is  the  influence  of  fear.  It 
dominates  the  entire  digestive  tract ;  it  causes  the  food  "  to  stick  in 
the  throat "  on  account  of  the  stoppage  of  the  secretion  of  saliva  and 
the  refusal  of  the  muscles  of  deglutition  to  act.  Fear  may  cause 
involuntary  defecation  by  increasing  the  peristalsis  of  the  intes- 
tines.* In  the  cases  of  which  we  hear  that  fear  caused  the  food  to 
remain  undigested  in  the  stomach  for  hours  and  to  be  finally  vom- 
ited, we  will  not  err  in  assuming  that  this  is  due  to  an  absence  of 
the  necessary  gastric  juice,  corresponding  to  a  similar  lack  of  saliva ; 
it  can  not  be  due  to  an  increased  peristalsis  of  the  stomach,,  since 
such  a  condition  would  favor  gastric  digestion. 

Although  it  is  beyond  doubt  that  both  stimulating  and  inhibi- 
tory impulses  are  conveyed  along  the  nerves  to  the  gastric  glands, 
yet  the  fact  nevertheless  remains  that  even  after  the  section  of  all 
these  nerves  the  secretion  does  not  cease,f  and  may  even  be  increased 
by  an  irritation  of  the  mucous  membrane.  It  is  not  improbable 
that  stimuli  pass  directly  or  indirectly  along  sensory  paths  to  the 
ganglion  cells  in  the  wall  of  the  stomach,  and  that  from  these  the 
glands  are  stimulated  to  activity.  This  has  not  yet  been  proved, 
and,  as  Heidenhain  has  already  said,  we  can  not  disregard  the  fact 

*  It  has  been  erroneously  supposed  that  defecation  results  from  the  relaxation 
of  the  sphincter.  But  the  rectum  is  normally  empty,  and  under  such  circum- 
stances defecation  can  not  result  from  simple  opening  of  the  sphincter.  Hence  it  is 
absolutely  impossible  to  explain  in  this  way  the  diarrhoea  which  results  from  fear. 

f  Diminution  in  the  secretion  as  well  as  changes  in  the  composition  of  the  gas- 
tric juice,  for  example,  lessening  of  the  amount  of  pepsin,  after  low  division  of  the 
vagi  (Jurgens),  have  been  frequently  reported. 


ABSORPTION  OP  THE  STOMACH.  455 

that  these  stimuli  may  act  on  the  glandular  cells  directly  without 
any  nervous  intervention.  It  has  been  demonstrated  through  gas- 
tric fistula  that  normally  even  the  contact  of  a  foreign  body  T\dth 
the  mucous  membrane  causes  a  circumscribed  secretion  at  the  place 
touched.  Only  the  mechanical  stimulation  operates  in  such  a  case, 
since  the  same  effect  is  produced  by  a  pebble  or  by  lightly  applying 
a  feather.  The  amount  of  the  secretion  thus  produced  is  very  small, 
but  immediately  increases  and  loses  its  circumscribed  character  if 
absorj^tion  of  even  innutritious  fluids  like  water  takes  place.  But 
the  entire  stomach  becomes  active  and  the  secretion  reaches  its  nor- 
mal strength  only  when  the  organ  contains  absorbable  nutritious 
material.  It  is  by  no  means  essential  that  these  fluids  enter  the 
stomach  as  such,  but  the  liquids  produced  by  the  solution  and  diges- 
tion of  solid  food  will  sufiice.  It  must  remain  an  open  question 
whether  this  absorbed  food  acts  indirectly  by  altering  the  blood,  or 
directly  by  affecting  the  nervous  elements  in  the  stomach  ;  yet  the 
reflex  character  of  this  stimulation  is  shown  by  its  extension  over 
the  entire  stomach.  We  must  therefore  assume  that  normally  the 
contact  of  food  with  the  mucous  membrane  causes  a  local  secretion 
which  is  possibly  produced  by  a  direct  stimulation  of  the  glands, 
and  that  at  the  same  time  the  absorption  of  food  reflexly  calls  the 
entire  secretory  apparatus  of  the  organ  into  activity. 

Absorption. — A  not  msignificant  portion  of  the  food,  both  fluid 
and  that  liquefied  in  the  stomach,  is  absorbed  by  the  stomach  itself.* 
As  the  walls  of  the  vessels  and  the  surround.ing  portions  of  the 
stomach  constitute  an  animal  membrane,  filtration  and  osmosis  may 
play  an  important  part.  This  explanation  of  absorption  appears  all 
the  more  acceptable  because  variations  in  this  process  which  are  be- 
lieved to  be  of  nervous  origin  may  easily  be  attributed  to  vaso- 
motor changes  in  the  blood,  and  even  the  lymph  vessels.  Absorp- 
tion is  also  directly  infiuenced  by  the  nervous  system.  The  first 
decisive  experiment  on  this  subject  was  made  by  Goltz ;  it  may  be 
briefly  described  as  follows :  In  two  frogs  the  heart  was  removed, 
thereby  rendering  circulation  impossible ;  then  the  brain  and  spinal 
cord  of  one  of  these  frogs  were  destroyed,  in  the  other  they  were 


*  [See  page  75.1 
30 


456  DISEASES  OP   THE  STOMACH. 

left  intact.  An  equal  amount  of  a  strychnine  solution  was  then 
injected  under  the  skin  of  the  hind  leg  of  each  of  them ;  after  a 
time  it  could  be  demonstrated  that  the  fore  leg  of  the  frog  with  the 
intact  central  nervous  system  contains  strychnine,  and  was  poisonous 
when  some  of  its  juices  were  injected  into  another  frog ;  but  the 
fore  leg  was  not  poisonous  in  the  frog  without  its  central  nervous 
system,  and  hence  contained  none  of  the  alkaloid.  As  there  was  no 
circulation  of  either  blood  or  lymph,  the  strychnine  must  have 
passed  from  the  hind  leg  to  the  fore  leg  by  diffusion,  or,  if  we  wish 
to  avoid  the  use  of  this  strictly  physical  expression,  by  absorption. 
The  experiment  therefore  proves  that  the  rapidity  of  this  absorption 
was  influenced  by  the  nervous  system. 

How  shall  we  think  of  this  influence  ?  Certainly  not  from  a 
purely  physical  standpoint,  as  if  the  nerves  had  altered  the  texture 
of  the  parts  of  the  body  involved,  and  in  this  way  changed  the  ra- 
pidity of  diffusion,  just  as  a  tense  membrane  affects  filtration  and 
diffusion  differently  from  a  relaxed  one.  We  would  rather  assume 
that  the  activity  of  the  individual  living  cells  had  been  altered, 
causing  them  to  absorb  and  give  up  the  strj'-chnine  solution  to  the 
neighboring  cells  more  rapidly.  The  existence  of  an  independent 
activity  of  the  living  cells  ought  not  to  surprise  us,  if  we  recall  the 
remarkable  functions  of  the  white  blood-cells  mentioned  on  page 
450,  or  if  we  remember  that  some  one-celled  animalcules  only 
choose  certain  algse  for  their  food. 

Absorption  may  thus  take  place  very  easily  in  the  stomach  Avith- 
out  any  influence  of  the  nervous  system  through  the  individual 
activity  of  the  cells  of  the  mucous  membrane  and  of  the  walls  of 
the  vessels,  and  even  of  the  blood  itself.  It  may  be  changed  by 
the  nervous  system  both  quantitatively  and  qualitatively.  It  is 
also,  to  some  extent,  affected  by  the  physical  laws  of  filtration  and 
diffusion,  which  in  turn  are  influenced  by  chemical  and  physical 
changes  in  the  circulation.  But  the  physical  relations  of  the  circu- 
lation are  regulated  by  a  direct  nervous  influence,  and  in  this  way 
the  nervous  system  may  exert  a  double  regulating  action  on  absorp- 
tion. The  paths  of  the  direct  nervous  regulation  of  the  cell  activity 
are  still  absolutely  unknown.  I  will  now  discuss  those  which  in- 
fluence the  circulation  of  the  blood. 


\'ASO-MOTOR  NERVES   OF   THE   STOMACH.  457 

Vaso-motor  Nerves. — Whenever  the  glands  of  a  part  or  of  the 
whole  stomach  are  in  active  secretion  it  is  constantly  observed  that 
the  secreting  area  has  an  increased  blood  supply.  The  arteries 
dilate,  the  blood  flows  more  rapidly,  and  reaches  the  veins  in  a  less 
oxidized  condition.  The  object  of  this  heightened  circulation  is 
manifestly  to  bring  a  sufficient  amount  of  material  for  secretion. 
These  changes  may  be  recognized  by  the  reddening  of  the  mucous 
membrane  and  a  marked  turgescence  and  erection  of  its  folds,  espe- 
cially of  the  large  ones  near  the  pylorus. 

How  does  this  vascular  dilatation  occur  ?  The  vaso-motor  nerves 
may  be  stimulated  directly — i.  e.,  either  by  mechanical  irritation 
produced  by  the  weight  of  the  ingesta,  or  by  their  rubbing  against 
the  walls  of  the  stomach  and  the  like,  or  by  a  chemical  stimulation 
proceeding  from  the  absorbed  materials.  The  extent  of  the  area  of 
dilatation  would  thus  correspond  to  the  area  to  which  the  directly 
stimulated  nerves  are  distributed.  But  the  irritation  of  the  mucous 
membrane  with  a  feather  or  a  solid  body  only  produces  a  local  red- 
dening corresponding  to  the  irritated  area.  This  W(mld  indicate  an 
immediate  influence  on  the  walls  of  the  vessels  themselves,  and  ren- 
ders the  above-described  transfer  of  the  stimulation  to  the  vaso- 
motor nerves  very  improbable.  A  similar  and  even  more  localized 
reddening  may  be  produced  in  the  skin  by  rubbing,  or  drawing  a 
line  on  it ;  chemical  irritants  (stimulating  plasters)  also  exert  a  local 
action.  These  manifestations  are  undoubtedly  due  to  a  local  action 
on  the  vascular  walls  ;  and  the  same  seems  to  be  true  of  the  stomach. 
Let  it,  however,  not  be  inferred  that  an  important  part  may  not 
be  played  by  the  true  vascular  reflex  which  follows  mechanical, 
chemical,  and  thermal  stimulation,  proceeds  along  the  sensory  nerves 
and  acts  through  the  medullary  and  spinal  centers  (Schmidt-Miihl- 
heim)  upon  the  vascular  nerves ;  for  we  also  know  that  holding  a 
piece  of  bacon  before  a  hungry  dog  causes  an  increase  in  the  tem- 
perature of  the  stomach  which  is  analogous  to  the  heightened  secre- 
tion. Possibly  the  same  influences  operate  here  as  in  secretion. 
The  reflex  stimuli  are  probably  associated  with  the  direct  local  ones, 
but  they  differ  from  the  latter  by  influencing  the  stomach  in  its  en- 
tire extent. 

We  are  justified  in  assuming  that  the  path  of  the  vaso-motor  im- 


458  DISEASES  OF  THE  STOMACH. 

pulses  is  along  the  sympathetic  nerves.  This  is  rendered  probable 
by  the  analogical  conditions  in  other  parts  of  the  body  as  well  as  by 
the  fact  that  very  moderate  vascular  changes  follow  the  division  of 
the  vagi.  Yaso-constrictor  nerves  probably  accompany  the  vaso- 
dilators everywhere  ;  this  may  explain  why  in  all  the  experiments  to 
demonstrate  the  relations  of  the  stomach  to  the  nervous  system  not 
alone  the  various  experimenters  have  differed  so  among  themselves, 
but  also  the  same  observer  has  obtained  such  contradictory  results 
on  repeating  the  same  experiment.  The  manifold  functions  of  the 
nerves  distributed  to  the  stomach  are  indicated  by  their  size ;  and  we 
also  have  many  undoubted  proofs  of  centrifugal  impulses  in  the 
effects  of  fear,  in  the  case  of  Richet  (page  453),  and  in  other  similar 
observations.  But  why  is  the  result  so  often  absent  on  stimulating 
the  vagus  and  sympathetic  ?  Why  do  we  get  one  result  in  some 
cases  and  the  contrary  in  others  ?  I  think  that  these  differences  are 
not  to  be  attributed  to  the  longer  or  shorter  interval  after  the  last 
meal,  to  the  various  degrees  of  fear  in  the  animals,  or  to  the  dif- 
ferent anaesthetics.  In  my  judgment  the  probable  explanation  is  as 
follows : 

If  the  vagus  is  stimulated,  the  inhibitory  effect  on  the  heart  is 
so  marked  that  for  a  long  time  the  presence  of  accelerating  fibers 
was  denied.  Had  the  effect  of  the  accelerating  fibers  exceeded  that 
of  the  inhibitory,  then  probably  the  former  would  only  have,  been 
recognized  at  first.  What  would  be  the  result  if  both  sets  of  fibers 
were  equally  powerful  ?  Stimulation  of  the  vagus  might  then  be 
followed  by  inhibition  at  one  time,  by  acceleration  at  another,  or  by 
no  effect  at  all.  Where  the  stimulation  of  both  sets  of  fibers  is  ex- 
actly equal,  the  result  will  be  negative.  But,  on  the  other  hand, 
slight  variations  in  the  point  of  application  of  the  electrodes,  differ- 
ent conditions  of  exhaustion  of  the  various  groups  of  fibers,  and  the 
like,  may  cause  the  result  to  be  positive.  The  condition  of  the 
heart,  the  organ  supplied  by  the  nerve,  will  also  influence  the  result. 
This  is  well  shown  in  the  experiment  in  which  the  sciatic  nerve  of 
a  dog  is  stimulated ;  if  the  blood-vessels  of  the  paw  have  been  di- 
lated by  heat,  the  irritation  will  cause  them  to  contract ;  but  if 
they  have  been  contracted  by  cold,  then  a  dilatation  wlQ  be  the 
result.     Let  us,  then,  suppose  that  all  the  inhibitory  and  stimulat- 


MOVEMENTS  OP  THE  STOMACH.  459 

ing  nerves  of  the  stomach  are  acting  equally  powerfully  ;  then  an 
explanation  would  be  given  why  strong  impulses  may  pass  along 
the  vagus  and  sympathetic  during  life,  and  yet  the  functions  of 
these  nerves  may  remain  unexplained  by  our  present  methods  of 
investigation. 

The  Movements  of  the  Stomach. — When  spontaneous  movements 
are  observed  in  an  excised  organ  we  very  frequently,  but  not 
always,  find  ganglion  cells  in  these  tissues ;  hence  we  are  led 
to  infer  that  these  movements  depend  upon  the  ganglion  cells. 
In  support  of  this  view  I  may  mention  the  active  peristaltic  move- 
ments of  an  excised  piece  of  intestine ;  here  we  have  the  gan- 
gHon  cells  of  Meissner's  and  of  Auerbach's  plexuses.  The  oesoph- 
agus executes  spontaneous  movements  twenty-six  hours  after 
excision,  and  here,  too,  numerous  ganglion  cells  may  be  found  in 
its  walls. 

The  conditions  in  the  stomach  are  exactly  the  same,  for  it,  too, 
manifests  spontaneous  movements  a  long  time  after  removal  from 
the  body,  and  in  its  walls  may  be  found  the  collections  of  ganglion 
cells  already  described  (page  453).  These  movements  differ  from 
those  normally  observed  in  being  less  regular  in  their  direction.  The 
peristaltic  and  the  antiperistaltic  movements  seem  to  alternate 
irregularly,  or  both  may  affect  various  parts  of  the  stomach  at  the 
same  time,  l^ormally,  by  means  of  fistulse  or  by  a  very  careful 
exposure  of  the  organ,  two  distinct  varieties  of  movements  have 
been  observed,  those  of  the  empty  viscus  and  those  during  diges- 
tion. In  the  former  condition  the  contractions  are  slower,  less  fre- 
quent, and  individually  less  energetic — i.  e.,  the  constrictions  are 
not  so  deep.  On  the  contrary,  while  secreting  they  are  rapidly 
executed,  much  more  frequent  in  occurrence,  and  each  contraction 
is  more  vigorous. 

A  great  variety  of  movements  has  been  observed.  Most  of  the 
waves  seem  to  proceed  from  the  pylorus  antiperistaltically  to  the 
middle  of  the  stomach,  and  then  run  back  to  the  pylorus  as  peri- 
staltic waves.  This  origin  of  the  movements  would  seem  to  indicate 
that  most  of  the  ganglion  cells  are  situated  at  the  pylorus.  The 
other  half  of  the  stomach  also  shows  various  movements,  but  they 
are  less  easily  traced.     A  permanent  transverse  constriction  across 


460  DISEASES  OP  THE  STOMACH. 

the  middle  of  the  organ,  the  so-called  cravate  de  Suisse,"^  and  many 
smiilar  features,  have  been  described,  but  I  will  not  enter  into 
further  details  concerning  them,  and  shall  simply  mention  two  im- 
portant circumstances :  First,  we  must  distinguish  between  move- 
ments of  the  ingesta  and  the  visible  movements  of  the  organ,  as 
they  by  no  means  coincide  with  each  other.  The  former  should  be 
such  that  the  food  makes  a  circuit  of  the  stomach  in  one  or  another 
direction.  Secondly,  at  no  time  is  the  peristaltic  motion  exclusively 
in  one  direction,  and  hence  it  is  impossible  to  determine  from  the 
outside  whether  or  not  the  chyme  is  forced  through  the  pylorus. 
Long  pauses  may  occur  in  the  movements  of  the  empty  as  well  as 
of  the  full  stomach ;  they  are  most  marked  in  the  former  and  may 
continue  for  hours,  but  when  full,  the  periods  of  repose  last  only  a 
few  minutes. 

Concerning  the  object  of  these  movements  I  may  premise  that, 
as  there  is  only  a  thin  layer  of  muscular  fibers,  the  amount  of  force 
generated  must  be  small,  and  that  any  mechanical  trituration  or 
grinding  of  the  food  is  out  of  the  question.  Such  a  mechanism  is 
not  compatible  with  a  secretory  apparatus,  since  strong  pressure 
would  be  injurious.  Hence,  in  birds,  where  such  grinding  and 
crushing  take  place,  we  observe  that  this  is  done  in  a  separate  mus- 
cular stomach,  while  secretion  occurs  in  another  stomach  specially 
arranged  for  the  purpose.  Therefore,  in  mammals  the  movements 
of  the  stomach  can  only  serve  the  twofold  purpose  :  first,  to  move 
the  ingesta  about  so  that  they  may  be  brought  into  thorough  con- 
tact with  the  gastric  juice,  and  to  stimulate  the  secretion  of  the  lat- 
ter by  this  mechanical  irritation  of  the  walls  of  the  organ ;  and,  sec- 
ondly, to  expel  the  chyme. 

The  origin  and  insertion  of  the  muscular  fibers  at  the  cardia  and 
pylorus  are  arranged  in  a  special  manner,  and  also  have  special 
functions.  While  there  is  very  little  agreement  as  to  the  functions 
of  these  sphincters,  yet  the  following  facts  may  be  accepted :  Both 
orifices  are  normally  kept  lightly  closed  by  the  tone  of  the  sphinc- 
ters.    The  opening  of  the  cardia  constitutes  the  last  part  in  the  act 

*  [This  term  has  been  applied  to  "  the  layer  of  oblique  muscular  fibers  which 
pass  from  behind  the  cardia  to  below  the  pylorus.  By  contracting,  they  form  a  con- 
tinuous canal  between  these  two  orifices,  separate  from  the  fundus." — Ed.] 


MOVEMENTS   OP  THE  STOMACH.  461 

of  deglutition.  On  introducing  the  finger  into  the  cardia  from 
within  the  stomach,  rhythmical  contractions  may  be  felt  Hke  those 
of  the  sphincter  ani  after  section  of  the  spinal  cord.  Yet  there  is 
no  rhythmical  opening  of  the  oesophagus,  for  this  would  permit  the 
regurgitation  of  food  ;  it  is  simply  a  "  wandering  up  and  down  "  of 
the  closed  orifice  of  the  stomach,  for  as  the  cardia  relaxes  the  foriner 
closes.  At  the  same  time  there  may  also  be  an  active  opening  of 
the  cardia  by  muscular  contractions  through  the  shortening  of  the 
muscular  fibers  passing  from  it  to  the  stomach.  The  pylorus  not 
possessing  such  bands  of  muscular  fibers  must  always  open  jpas- 
sively.  This  occurs  during  the  later  stages  of  gastric  digestion, 
partly  as  a  result  of  the  increased  pressure  exerted  on  it  by  the  food 
through  the  heightened  peristalsis,  and  also  partly  on  account  of  the 
increased  amount  of  hydrochloric  acid  in  the  chyme.  The  latter 
does  not  all  pass  into  the  duodenum  at  once,  but  intermittently ; 
this  may  be  due  to  the  fact  that  the  pylorus  has  rhythmical  move- 
ments like  those  of  the  cardia. 

As  already  mentioned,  section  of  all  the  nerves  distributed  to  the 
stomach  does  not  cause  the  cessation  of  all  its  various  movements, 
but  only  weakens  them,  and  abolishes  the  slight  degree  of  regularity 
and  co-ordination  which  they  ha  dpreviously  manifested.  In  mam- 
mals, stimulation  of  the  vagus  usually  causes  peristaltic  movements 
of  the  organ  or  intensifies  those  already  present.  As  a  rule,  the 
pylorus  also  contracts  powerfully,  but  a  coincident  contraction  of 
some  duration  has  not  always  been  observed.  The  majority  of  ex- 
perimenters believe  that  similar  but  far  less  powerful  movements 
follow  stimulation  of  the  sympathetic.  On  the  other  hand,  stimula- 
tion of  the  splanchnic  nerves  in  the  abdominal  cavity  is  said  to  stop 
the  spontaneous  contractions  of  the  pylorus  (Oser,  Bastianelli). 

Probably  the  action  of  the  different  nerves  depends  upon  the 
condition  of  the  stomach  (Contejean).  If  the  stomach  is  in  motion 
as  the  result  of  stimulation  from  the  vagus,  the  action  of  the  sym- 
pathetic will  be  inhibitory ;  but  it  will  provoke  peristaltic  action 
if  the  stomach  is  at  rest.  On  the  other  hand,  the  stimulation  of 
the  vagus  has  no  effect  on  movements  which  have  been  called  forth 
by  the  sympathetic. 

Yet  all  these  experimental  stimulations  in  mammals  have  an  in- 


462  DISEASES   OF  THE   STOMACH. 

definite  and  uncertain  character;  their  success  is  usually  not  great 
and  by  no  means  constant.*  "We  know  only  of  the  absolutely  clear 
and  satisfactory  experiment  on  frogs,  and  it  may  indeed  be  said 
that  it  is  the  only  positive  experiment  on  the  influence  of  the  nerves 
upon  the  movements  of  the  stomach.  I  refer  to  Groltz's  crucial  test 
with  curarized  frogs.f  In  spite  of  Goltz's  warning,  this  experi- 
ment is  nearly  always  falsely  interpreted.  The  main  point  at  issue 
is  really  a  stimulation  which  results  from  destroying  the  brain  and 
cord,  and  which  reaches  the  stomach  through  the  vagi.  The  same 
effect  may  therefore  be  obtained  by  laying  this  nerve  bare  and 
stimulating  it. 

Vomiting. — Magendie  thought  that  vomiting  was  exclusively  due 
to  the  action  of  the  abdominal  pressure,  which  is  entirely  independ- 
ent of  the  stomach.  As  is  known,  he  replaced  this  viscus  with  a 
pig's  bladder,  and  caused  the  expulsion  of  its  contents  by  injecting 
tartar  emetic  into  the  blood.  But  Tantini  showed  that  this  experi- 
ment was  no  longer  successful  after  the  cardia  was  left  attached  to 
the  oesophagus.  Therefore,  during  vomiting  there  must  be  an  active 
opening  of  the  cardia  in  the  manner  already  described.  At  the 
same  time  that  the  cardia  is  opened  the  pylorus  is  tightly  closed, 
and  powerful  peristaltic  and  antiperistaltic  waves,  especially  the 
latter,  traverse  the  organ ;  the  diaphragm  descends  and  becomes  less 
arched ;  the  abdominal  muscles  exert  pressure  on  the  stomach  partly 
directly,  partly  indirectly,  by  compressing  all  the  abdominal  viscera. 
The  larynx  descends,  the  base  of  the  tongue  is  depressed,  and  the 
upper  part  of  the  body  is  bent  forward.     All  these  movements  are 


*  There  is  no  lack  of  recent  positive  assertions,  but  confirmation  is  still  wanting ; 
for  example,  see  the  review  of  R.  Kobert  in  Schmidt's  Jahrbiicher,  Bd.  ccxi,  S.  244  • 
and  Bd.  ccxv,  S.  13. 

f  Vide  Ewald.  Klinik,  etc.,  I.  Theil,  3te  Auflage,  S.  76.  [In  brief,  the  experi- 
ment is  as  follows :  Two  frogs,  whose  oesophagi  and  stomachs  have  been  laid  bare, 
are  suspended  vertically  after  having  been  curarized ;  in  addition,  in  the  one  frog 
the  brain  and  spinal  cord  have  been  destroyed.  A  dilute  solution  of  common  salt 
is  now  poured,  drop  by  drop,  into  their  mouths  :  in  the  normal  frog  the  stomach 
and  oesophagus  are  distended  and  full  of  fluid,  almost  motionless,  with  only  an  oc- 
casional peristaltic  wave,  and  look  just  like  a  distended  pig's  bladder ;  in  the  frog 
without  the  central  nervous  system  the  gullet  and  stomach  are  empty,  with  active 
peristaltic  waves  from  above  downward,  and  look  like  a  rosary.  The  same  results 
are  obtained  by  dividing  the  vagi,  but  electrical  stimulation  of  this  nerve  produces 
only  slight  contractions. — Ed.] 


SENSIBILITY  OP  THE   STOMACH.  463 

intended  to  facilitate  the  evacuation  of  tlie  contents  of  tlie  stomach. 
Indeed,  the  abdominal  pressure  may  be  said  to  exert  most  of  the 
force  necessary  for  the  act.  This  is  well  shown  in  the  easy  vomit- 
ing of  children  ;  here  we  may  see  the  entire  contents  of  the  stomach 
ejected  from  the  mouth  in  a  large,  continuous  stream,  such  as  could 
never  be  caused  by  peristaltic  contractions.  It  should  also  be  ob- 
served that  the  ability  to  vomit  lessens  with  years,  especially  as  fat 
develops  in  the  abdominal  muscles,  so  that  even  in  one's  student 
days  vomiting  may  only  be  accomplished  by  artificial  pressure  on 
the  abdomen,  even  though  marked  nausea  be  present. 

Of  the  nerves  participating  in  the  act  of  emesis  we  are  here  only 
interested  in  those  distributed  to  the  stomach.  Mechanical  and 
electrical  stimulation  of  the  gastric  mucosa  easily  excites  vomiting, 
since  it  seems  that  it  is  transmitted  along  the  sympathetic  to  the 
vomiting  center  in  the  medulla.  This  has  not  yet  been  demon- 
strated with  the  other  sensory  stimuli,  and  it  seems  that  most  of  the 
emetics  can  only  act  on  this  center  after  they  have  passed  into  the 
blood.*  The  centrifugal  impulses  which  reach  the  stomach  during 
vomiting  proceed  along  the  vagi,  and  effect  the  proper  co-ordination 
of  the  movements  of  the  stomach  with  the  other  muscular  contrac- 
tions essential  to  this  act.  After  section  of  the  vagi  this  co-ordi- 
nation is  lost,  and,  although  vomiting  is  not  impossible,  yet  it  is 
rendered  very  difficult.  It  will  then  only  occur  when  by  chance  the 
increase  in  the  abdominal  pressure  and  the  opening  of  the  cardia 
happen  to  be  simultaneous. 

Sensibility  of  the  Stomach. — The  stomach  is  unquestionably  sensi- 
tive both  upon  the  mucosa  as  well  as  on  the  serosa.  A  hard  oeso- 
phageal bougie  is  felt  the  moment  it  touches  the  walls  of  the  stomach. 
So,  also,  in  making  a  gastric  fistula  the  patient  feels  the  thermo- 
cautery as  it  touches  the  stomach  from  without.     The  sensitiveness 


*  Openchewski  makes  a  distinction  between  central  and  peripheral  emetics. 
The  latter,  the  most  important  of  which  are  cupric  sulphate  and  tartar  emetic,  may 
produce  their  effects  from  any  part  of  the  digestive  tract.  Apomorphine  acts  cen- 
trally, but  ceases  when  the  corpora  quadrigemina  are  destroyed.  The  center  for 
the  movements  of  the  cardia  and  the  stomach  proper  has  been  located  here.  Open- 
chewski believes  that  the  inhibitory  center  for  the  cardia  is  situated  at  the  junction 
of  the  anterior  inferior  extremity  of  the  caudate  nucleus  with  the  lenticularnucleus. 
(See  Ewald,  Klinik,  etc.,  3te  Auflage,  I.  Theil,  p.  77.) 


464:  DISEASES  OF  THE  STOMACH. 

is  very  limited,  and  strong  stimuli  are  required  to  produce  these 
effects.  Normally  we  do  not  feel  our  stomachs  ;  we  neither  feel  the 
weight  of  the  ingesta  nor  do  we  know  where  the  food  lies,  its  tem- 
perature, or  chemical  properties,  whether  acid,  alkaline,  or  bitter ; 
neither  do  we  feel  the  peristalsis  called  forth  by  eating.  But  the 
powerful  stimuli  above  mentioned  prove  that  even  the  healthy  stom- 
ach is  not  utterly  devoid  of  sensation ;  and  as  all  sensory  nerves 
respond  to  the  four  different  kinds  of  stimuli,  viz.,  mechanical, 
electrical,  thermal,  and  chemical,  these  may  also  be  at  once  assumed 
of  the  sensory  nerves  of  the  stomach.  The  efficiency  of  the  elec- 
trical and  chemical  stimuli  has  also  been  demonstrated  ;  this,  com- 
bined with  the  perception  of  the  bougie  and  the  thermo-cautery 
mentioned  above,  demonstrates  that,  to  a  certain  extent  at  least,  all 
of  these  kinds  of  stimuli  are  effective.  The  thinness  of  the  walls  of 
the  stomich  may  at  times  render  it  difficult  to  decide  whether  the 
perception  has  been  on  its  inner  or  outer  surface  ;  it  has  indeed  been 
suggested  that  in  some  cases,  as,  for  example,  the  temperature  of  the 
food,  the  sensations  are  not  in  the  stomach  but  in  the  abdominal 
parietes.  Even  if  this  be  true  under  certain  conditions,  the  fact 
nevertheless  remains  that  the  various  stimuli  mentioned  may  all  be 
perceived  in  the  mucous  membrane  of  the  stomach. 

Pathologically  the  sensitiveness  may  be  increased  even  where 
the  nerves  are  not  exposed,  as  happens  in  gastric  ulcer,  cancer,  etc. 
Under  such  circumstances  irritating  ingesta  which  have  been  swal- 
lowed may  cause  pain,  and  even  touching  the  wall  of  the  stomach 
with  the  bougie  may  produce  unpleasant  sensations. 

To  anticipate  what  will  be  discussed  later  on,  I  will  add  that, 
although  we  do  not  normally  feel  whether  the  stomach  is  empty  or 
not,  yet  we  do  know  when  it  is  overfilled  ;  this  may  be  due  to  dis- 
tention and  traction  on  the  gastric  walls. 

All  these  sensations  affect  consciousness  by  means  of  the  pneu- 
mogastric  nerves,  since  the  complete  division  of  these  nerves  will 
prevent  every  conscious  perception  of  the  stomach.* 

*  [An  elaborate  study  of  the  sensibility  of  the  stomach  and  its  influence  on 
digestion  has  been  made  by  Sollier.  Kellogg's  translation  may  be  found  in  Modern 
Medicine.  1895,  vol.  iv,  pp.  143  et  seq.  This  subject  is  destined  to  play  an  impor- 
tant part  in  the  future  investigations  on  the  neuroses  of  the  stomach, — Ed.] 


HUNGER,  465 

Hunger. — The  consideration  of  the  causes  and  localization  of  the 
sensation  of  hunger  is  best  taken  up  after  the  above  discussion  of 
the  sensibility  of  the  stomach.  Formerly  the  stomach  was  uni- 
versally regarded  as  the  cause  of  hunger.  Thus,  Haller  thought  it 
was  due  to  the  rubbing  together  of  the  walls  of  the  empty  stomach. 
But  hunger  is  unquestionably  a  general  sensation.  It  is  due  to  the 
impoverishment  of  the  blood,  and  has  been  well  called  the  appeal  of 
the  impoverished  metabolism  to  the  brain.  Such  being  its  cause,  it 
can  only  be  definitely  satisfied  by  supplying  the  blood  with  fresh  nu- 
triment. It  has  been  demonstrated  in  animals  that  hunger  is  abol- 
ished by  injecting  nutritious  substances  into  the  blood,  l^aturally, 
the  experiment  with  the  corresponding  general  sensation  of  thirst 
is  much  more  easily  carried  out,  since  the  simple  injection  of  water 
easily  relieves  it. 

Kecently  there  has  been  no  lack  of  contradictory  statements, 
only  the  more  important  of  which  I  will  now  mention.  Thus,  it  has 
been  said  that  hunger  is  due  to  the  emptiness  of  the  stomach.  But 
rabbits,  guinea  pigs,  and  other  herbivorse,  never  have  empty  stom- 
achs ;  indeed,  the  organ  retains  the  same  degree  of  fullness  which 
it  had  after  the  last  meal,  till  the  fresh  food  which  has  been  taken 
pushes  part  of  the  contents  on  through  the  pylorus.  Here  we  can 
not  speak  even  of  a  relative  emptiness  of  the  stomach  which  might 
cause  the  sensation.  In  carnivora  the  viscus  is  empty  hours  before 
hunger  is  felt,  and  in  newborn  infants  hunger  is  only  manifested 
some  time  after  tying  the  cord,  while  normally  the  stomach  is  empty 
up  to  this  time  without  giving  rise  to  this  feeling. 

Furthermore,  it  has  been  attempted  to  make  not  alone  the  emp- 
tiness of  the  stomach  a  direct  cause,  but  also  the  simultaneous  in- 
creased peristalsis  or  the  lessening  of  the  secretion  of  the  gastric 
juice,  or  even  its  accumulation  in  the  gastric  glands.  But  direct 
observation  shows  that  all  these  suppositions  are  not  tenable,  and 
therefore  can  not  be  advanced  in  explanation  of  this  feeling.  On 
the  other  hand,  section  of  the  vagi  affords  important  proof  that 
hunger  is  a  universal  sensation,  since  it  may  be  felt  even  after  all 
the  fibers  of  these  nerves  have  been  divided.  But,  as  I  have  already 
mentioned,  after  this  has  been  done  no  more  perceptions  can  pro- 
ceed from  the  stomach  to  consciousness. 


466  DISEASES  OP  THE  STOMACH. 

The  vagi  Laving  been  divided,  reflexes  might  be  transmitted  to 
the  brain  by  the  sympathetic.  Such  a  function  is  generally  not  ac- 
cepted ;  hence  it  has  been  suggested  whether,  after  the  suppression 
of  perceptible  stimuli  from  the  stomach  by  division  of  the  vagi, 
other  kinds  of  excitation  of  the  organ  which  are  not  perceived  as 
such  by  consciousness,  may  not  affect  the  higher  centers,  and  thus 
cause  the  sensation  of  hunger.  But  the  latter  may  be  felt  even  after 
the  simultaneous  division  of  both  the  vagi  and  sympathetic.  There- 
fore the  hunger  center  requires  no  connection  with  the  stomach. 

Where  shall  we  search  for  the  center  ?  At  all  events,  not  in  the 
cerebrum  or  cerebellum,  for  monsters  born  without  these  organs 
give  undoubted  manifestations  of  hunger.  Until  recently  it  was 
observed  that  pigeons  in  which  the  cerebrum  had  been  extirpated 
never  voluntarily  took  food  ;  and  as  they  made  no  movements  which 
could  indicate  hunger,  even  starving  to  death  while  quietly  resting 
on  a  heap  of  peas,  it  was  naturally  supposed  that  with  the  destruc- 
tion of  the  cerebrum  the  sensation  of  hunger  had  also  been  lost. 
But  in  all  experiments  on  the  central  nervous  system  very  great 
care  must  be  exercised  and  inferences  very  cautiously  drawn,  l^early 
one  year  after  the  destruction  of  the  cerebrum  in  the  usual  manner 
I  saw  a  pigeon  again  begin  to  take  solid  and  liquid  food  voluntarily. 
This  seems  to  have  been  the  first  case  of  this  kind  observed.  It  has 
also  been  verified  by  Schrader,  but  he  asserts  that  pigeons  can  only 
aa-ain  learn  to  eat  when  renmants  of  the  frontal  lobes  have  been  left 
intact.  On  the  other  hand,  the  same  writer  saw  frogs  catch  and 
devour  flies  after  complete  removal  of  the  cerebrum.  Therefore, 
this  center  does  not  exist  in  the  cerebrum,  and  it  has  properly  been 
located  in  the  medulla  ;  the  supposition  is  that  it  is  here  stimulated 
directly  without  the  intervention  of  peripheral  nerves  by  the  blood 
circulating  about  it,  whenever  the  percentage  of  nutritious  material 
in  the  blood  has  been  sufficiently  lowered  by  giving  it  up  to  the 
tissues. 

But  how  can  we  reconcile  this  with  the  fact  that  most  people 
locate  the  sensation  of  hunger  in  a  particular  spot  ?  A  comparison 
with  another  general  sensation  which  is  universally  recognized  as 
such — i.  e.,  sleep — teaches  us  how  easily  such  general  sensations  may 
be  combined  with  local  perceptions.     When  we  are  tired,  the  feeling 


HUNGER.  467 

of  general  languor  and  the  desire  to  sleep  is  accompanied  by  a  heavi- 
ness of  the  eyelids  which  is  often  supplemented  by  itching  or  burn- 
ing. Here  we  distinctly  feel  that  the  general  fatigue  is  associated 
with  a  localized  feeling  in  the  eyelids.  But  in  hunger  the  gen- 
eral sensation  is  so  indefinite  that  it  is  usually  mistaken  for  the 
simultaneous  local  feehng.  Hence,  hunger  is  more  or  less  posi- 
tively located  by  most  persons  in  a  definite  part  of  the  body.  Yery 
interesting  in  this  connection  is  the  statement  of  Schiff,  who  asked 
a  large  number  of  soldiers  where  they  experienced  the  sensation  of 
hunger.  Several  located  it  in  the  chest  and  neck,  twenty-three  over 
the  sternum,  four  did  not  know  where  to  place  it,  and  only  two 
mentioned  the  stomach.  Marked  individual  differences  undoubtedly 
exist  in  the  localization  as  well  as  the  intensity  of  this  sensation. 
After  a  long  fast  many  only  experience  a  moderate,  vague  feeling 
of  oppression,  while  others  regularly  have  an  intense,  almost  painful 
sensation  before  the  usual  meal  hour.  Yet  in  the  majority  of  per- 
sons who  can  observe  themselves  somewhat  closely  hunger  seems  to 
begin  merely  with  a  vague  oppression  in  the  epigastrium.  This 
localized  sensation  accompanying  the  general  feeling  is  really  cen- 
tral— i.  e.,  it  results  from  the  stimulation  of  the  centers  themselves 
without  any  demonstrable  intervention  of  the  peripheral  nerves. 
The  central  irritation  is  then  transferred  peripherally — that  is,  the 
cause  of  our  perception  is  falsely  referred  to  the  periphery.  Such 
or  analogous  "  eccentric  transfers "  are  of  frequent  occurrence  ; 
thus,  if  the  ulnar  nerve  is  injured,  the  pain  is  felt  in  the  little  fin- 
ger. However,  in  this  example  the  irritant  does  not  act  upon  the 
center,  as  in  the  sensation  of  hunger,  but  only  upon  the  nerve  at  a 
place  which  is  more  centrally  situated  than  the  site  to  which  the 
sensation  is  referred  ;  but  otherwise  it  is  an  exactly  analogous  ec- 
centric transfer  of  a  sensation. 

Against  this  interpretation  of  the  localized  feeling  of  hunger  as 
a  central  perception  it  might  be  said  that  the  local  irritation  of  the 
stomach  is  often  followed  by  very  positive  manifestations  of  hunger. 
Thus,  the  first  effect  of  a  growing  cancer  of  the  stomach  may  be  a 
ravenous  appetite.  But  why  may  not  an  "  eccentric  sensation  "be 
simulated  by  one  which  is  peripheral  ?  Touching  the  spokes  of  a 
rapidly  revolving  wheel  at  times  causes  a  sensation  like  that  of  the 


468  DISEASES  OF  THE  STOMACH. 

"  falling  asleep  "  of  a  finger.  On  the  other  hand,  if  this  feeling  of 
hunger  suddenly  passes  away,  as  through  disgust,  it  is  highly  im- 
probable that  the  perception  of  the  existing  local  irritation  should 
have  been  suppressed,  as  such  an  inhibition  usually  results  only 
from  the  most  intense  psychical  excitement.  In  the  heat  of  a  battle 
the  pain  of  a  wound  may  not  be  felt  even  if  the  attention  has  been 
casually  directed  to  it ;  here  stimuh  are  acting  which  aif  ect  the  mind 
to  the  highest  degree.  But  if  these  stimuli  be  feeble,  as,  for  exam- 
ple, the  receipt  of  some  unexpected,  aifecting  news,  be  it  good  or 
bad,  we  can  nevertheless  always  positively  say  whether  there  is  any 
abnormal  sensation  in  any  part  of  the  body  ;  our  judgment  will  in 
no  wise  be  different  than  usual.  At  all  events,  in  such  a  case  we 
can  remove  this  inhibition  which  may  finally  have  resulted  from 
the  mental  excitement  by  directing  the  attention  to  the  part  of  the 
body  in  question.  Bat  if  through  mental  excitement  we  have  lost 
our  desire  for  food — I  will  rather  say  the  sensation  of  hunger — we 
may  sit  down  at  the  table,  we  may  long  to  eat,  we  may  concentrate 
our  entire  attention  upon  the  appetite,  yet  this  feeling  of  hunger 
remains  away.  What  trifling  excitements  sometimes  cause  this  in 
many  persons — the  news  that  a  good  friend  is  coming,  the  falling  of 
a  fly  in  the  soup,  or  the  narration  of  disgusting  stories  !  It  is  cer- 
tainly an  interesting  fact  that  the  appetite  may  be  extinguished  by 
psychical  influences,  in  spite  of  the  most  strenuous  efforts  of  the 
eater  not  to  be  influenced  by  these  recitals.  It  will  always  be  futile 
to  use  such  feeble  mental  efforts  to  suppress  sensations  due  to  pe- 
ripheral irritants,  even  if  they  be  slight  or  proceed  from  without  or 
within  the  body.  The  abnormal  sensation  will  always  return  when- 
ever the  attention  is  directed  to  one's  own  body. 

It  is  different  with  sensations  of  central  origin.  Continuous  self- 
observation  will  at  times  show  that  a  headache  may  entirely  disap- 
pear as  a  result  of  moderate  mental  excitement ;  possibly  even  more 
convincing  is  the  feeling  of  fatigue  which  so  often  leaves  us  after 
slight  mental  exertion  and  then  is  craved  back  again  in  vain.  I 
therefore  believe  that  hunger  is  of  purely  central  orgin,  and  that  it 
is  only  indirectly  connected  with  the  "  rumblings  of  an  empty 
stomach." 

Just  as  we  can  drive  away  sleep  for  a  short  time  by  abolishing 


HUNGER.  469 

the  sensations  by  whicli  it  manifests  itself  locally,  so  can  we  do  the 
same  with  hunger.  "Washing  the  eyes  with  cold  water  will  keep 
one  awake.  Hunger  may  be  put  off  by  introducing  indigestible 
substances  into  the  stomach  or  by  compressing  this  viscus  with  a 
tight  belt,  as  is  frequently  done  by  the  common  people.  But  both 
of  these  general  sensations  have  only  been  treated  symptomatically, 
and  have  not  really  been  suppressed.  It  is  merely  using  the  familiar 
method  of  obscuring  one  sensation  by  a  stronger  one  at  the  site  of 
the  former,  or  where  this  may  be  referred  in  the  periphery. 

Even  if  we  thus  succeed  in  removing  the  manifestations  of  hun- 
ger which  appeal  most  powerfully  to  consciousness,  true  hunger  can 
nevertheless  be  satisfied  only  by  introducing  nutritious  material  into 
the  circulation.  But  it  is  a  well-known  fact  that  when  we  are  very 
hungry  and  have  waited  too  long  after  the  usual  time  of  eating,  so 
that  the  stomach  "  rumbles,"  we  yawn  and  feel  weak,  etc.,  a  few 
bites  will  satisfy  us  and  relieve  these  distressing  symptoms.  But  is 
it  possible  that  in  so  short  a  time  sufficient  food  has  been  absorbed 
to  satisfy  this  want  ?  By  no  means.  Only  the  more  urgent  mani- 
festations have  been  assuaged,  exactly  as  happens  after  swallowing 
indigestible  substances  and  tightening  a  belt.  Eating  a  meal  first 
satisfies  the  urgent  signs  of  hunger,  but  we  are  not  really  satiated 
then ;  the  true  hunger  is  appeased  very  slowly  during  the  meal  and 
the  period  of  digestion.  The  true  sign  of  being  sated  is  that  condi- 
tion of  the  blood  which  no  longer  stimulates  the  hunger  center ; 
hence  the  latter  ceases  to  send  out  impulses  to  the  other  centers 
which  cause  this  feeling  to  be  manifested. 

According  to  this  theory,  that  satiation  denotes  a  state  of  quies- 
cence of  the  hunger  center,  the  feeling  is  of  a  negative  character. 
Hence  it  might  be  objected  that  it  would  then  be  impossible  to  be 
especially  "  full "  after  a  large  meal,  I  might  almost  say  over-sati- 
ated. But  in  order  to  show  that  this  is  really  an  objection  to  the 
theory,  it  must  first  be  demonstrated  that  the  sensation  is  due  to  an 
excess  of  nutrition  in  the  blood  above  what  is  needed  for  satiation 
This  is  evidently  not  the  case.  We  can  not  feel  whether  more 
nourishment  than  is  necessary  is  circulating  in  the  blood,  just  as  we 
are  unable  to  tell  whether  the  sleep  from  which  we  have  just 
awakened  will  suffice  for  a  longer  or  shorter  time.     Consequently, 


470  DISEASES  OP  THE  STOMACH. 

after  having  satisfied  ourselves  at  a  meal,  and  provided  we  have  no 
other  guide  than  our  sensations,  we  will  not  know  whether  we  will 
feel  hungry  sooner  or  later.  The  real  cause  of  the  varying  degrees 
of  satiation  after  a  meal  is  simply  the  distention  of  the  stomach,  for 
which,  as  already  stated  (page  467),  we  have  a  distinct  perception. 
Whether  the  stomach  feels  especially  full  or  not  depends  on  the 
usual  size  of  the  meal.  If  we  give  only  meat  and  wheat  bread  to 
an  Irish  peasant  who  is  accustomed  to  distend  his  stomach  with 
potatoes,  he  will  feel  sated  after  having  taken  a  much  larger  amount 
of  nutriment  than  usual ;  in  spite  of  this,  he  will  not  feel  that  he 
has  eaten  too  much,  unless  his  stomach  is  unusually  distended.  On 
the  other  hand,  if  we  give  innutritions  and  bulky  food  to  a  person 
whose  chief  article  of  diet  has  been  meat,  he  will  feel  oversated 
when  his  stomach  is  uncommonly  distended,  even  if  he  has  taken 
less  nourishment  than  usual.  Hence  the  feeling  of  oversatiation  is 
really  not  due  to  such  a  condition,  but  is  to  be  regarded  only  as  a 
new  and  positive  sensation,  resulting  from  an  unusual  distention  of 
the  stomach,  and  which  to  some  extent  may  be  regarded  as  a  warn- 
ing against  overloading  this  organ. 

Finally,  I  must  discuss  the  appetite.  Let  us  again  use  the  simile 
between  hunger  and  general  fatigue.  If  we  are  tired  and  wish  to 
sleep,  it  is  essential  that  certain  parts  of  the  brain  should  not  be  ex- 
cited. The  absence  of  such  excitement  puts  us  into  the  condition 
of  sleepiness.  ]^ot  alone  do  we  wish  to  sleep,  not  alone  do  we  feel* 
the  need  of  repose,  but  we  also  experience  the  sensation  that  we  will 
soon  be  asleep  if  we  simply  keep  quiet.  The  same  exertions  which 
have  at  first  tired  us  may  excite  us  if  they  are  kept  up  too  long. 
Then  we  are  overtired.  In  the  same  way  certain  mental  exertions 
may  be  exciting ;  in  both  cases,  in  spite  of  the  fact  that  we  feel  a 
very  well  marked  need  of  rest,  we  are  yet  unable  to  sleep — ^that  is, 
we  are  not  drowsy. 

Appetite  bears  the  same  relation  to  hunger  that  drowsiness  does 
to  sleep,  l^ormally,  both  sensations,  hunger  and  appetite,  precede 
the  taking  of  food  ;  but  we  may  be  overhungry  as  we  may  be  over- 
tired. Of  the  mental  excitements  which  may  suppress  hunger  I 
have  already  spoken.  Sensory  stimuli  act  in  this  same  way  upon 
drowsiness  and  appetite ;  a  cold  sponging  may  awaken  us,  and  an 


APPETITE.  471 

offensive  taste  or  smell  may  spoil  our  appetites.  Finally,  however, 
sleep  as  well  as  limiger  overcome  all  obstacles  and  imperatively  de- 
mand their  rights. 

We  must  therefore  assume  that  the  true  hunger  center,  which  is 
influenced  by  the  impoverished  condition  of  the  blood,  sets  into  ac- 
tion a  large  series  of  secondary  centers,  which  in  their  turn  produce 
the  manifest  signs  of  hunger  ;  and  upon  their  activity  depends  the 
occurrence  of  appetite.  If  we  have  no  appetite,  as,  for  example, 
when  we  are  overhungry,  then  these  centers  are  inhibited  ;  the  most 
pressing  and  distinct  signs  of  hunger  which  urge  us  to  eat  are  absent, 
and  only  a  vague  general  feeling  tells  us  that  we  are  nevertheless 
not  sated.  However,  the  nature  of  appetite  consists  not  alone  in  a 
demand  for  taking  food,  and  a  preference  for  certain  articles  of  diet 
(if  this  were  the  case,  then  there  would  be  an  analogous  sensation 
in  the  condition  of  thirst,  which,  however,  does  not  exist,  and  for 
which  also  there  is  no  word  in  the  language),  but  the  appetite  may 
also  exclude  certain  articles  of  diet  which  are  relished  at  another 
time.  The  latter  lends  a  special  characteristic  to  this  feeling.  Of 
the  many  instances  which  might  be  quoted  to  illustrate  this  I  will 
simply  recall  the  striking  repugnance  toward  fats  in  jaundice.  The 
mere  sight  of  butter  may  excite  disgust  even  in  persons  who  have 
been  fond  of  butter  or  fatty  food.  I  do  not  know  any  analogous 
instances  of  this  regarding  thirst — that  is,  in  so  far  as  the  fluids  are 
simply  to  allay  thirst,  but  are  not  to  have  any  great  nutritive  value, 
as  milk,  chocolate,  etc.  Here  it  is  only  overindulgence  which 
causes  a  disgust  toward  favorite  beverages. 

The  taking  of  food  brings  into  action  a  very  large  number  of 
special  centers.  Among  these  are  the  centers  for  taste  and  smell, 
the  secretion  of  saliva,  the  voluntary  and  involuntary  acts  of  deglu- 
tition, etc.  "We  also  have  a  very  distinct  feeling  whether  a  certain 
article  will  influence  the  taking  of  food  favorably  or  unfavorably. 
Even  the  thought  of  them  will  act  in  the  same  way  as  the  dishes 
themselves,  but,  of  course,  to  a  feebler  degree.  If  we  notice  that 
the  smell  or  taste  of  a  dish  is  unpleasant,  that  the  secretion  of  saliva 
is  lessened,  and  that  deglutition  is  inhibited  (a  sensation  which  is 
characterized  in  its  most  marked  form  as  a  "  zugeschnurte  Kehle  "), 

then  this  article  of  food  becomes  repugnant  to  us.     Such  an  occur- 
31 


472  DISEASES  OF  THE  STOMACH. 

rence  will  explain  wlij  this  peculiarity  does  not  occur  in  the  analo- 
gous sensation  of  tliirst,  or,  if  present,  is  very  feebly  marked  ;  that 
is,  the  act  of  drinking  does  not  call  these  centers  of  salivary  secre- 
tion, and  deglutition,  etc.,  into  play  to  the  same  degree.  l!Taturally, 
a  favorable  influence  on  the  above  centers  will  cause  a  longing  for 
special  foods. 

In  my  opinion,  appetite  is  due  (1)  to  the  excitation  of  those 
centers  which  cause  the  manifest  symptoms  of  hunger,  and  the  ac- 
tion of  which  is  regulated  by  the  true  hunger  center  ;  (2)  to  the 
favorable  or  unfavorable  stimulating  or  inhibitory  action  of  the 
secondary  centers  concerned  with  the  taking  of  food. 


CHAPTER  X. 

THE    NEUKOSES    OF    THE    STOMACH. 

The  term  neuroses  of  the  stomach  includes  all  those  conditions 
which  manifest  themselves  as  disturbances  of  digestion  without 
demonstrable  anatomical  lesion  in  that  organ  ;  or,  if  such  be  pres- 
ent, they  are  only  secondary  ;  in  other  words,  the  neuroses  of  the 
stomach  are  the  functional  disturbances  as  opposed  to  the  so-called 
organic. 

Our  knowledge  of  this  subject  is  by  no  means  recent ;  for  ex- 
ample, a  description  which  was  excellent  for  the  time  in  which  it 
was  written  may  be  found  in  Comparetti  (1790).*  Many  writers 
have  been  engaged  on  this  theme,  especially  the  French  and  Eng- 
lish, including  Barras,  Beau,  Trousseau,  Chambers,  Budd,  Fother- 
gill,  Fenwick,  and  others.  Yet  since  then  great  advances  have  been 
made  as  the  result  of  the  labors  of  investigators  in  every  land,  and 
in  Germany  especially  by  the  work  of  Leube.  It  must  be  admitted 
that  our  knowledge  is  chiefly  of  a  descriptive  nature,  and  that  the 
etiology  of  the  disturbances  is  far  from  being  thoroughly  under- 
stood. However,  if  we  remember  that  the  stomach  is  the  center  of 
a  far-reaching  plexus  whose  cerebral  and  sympathetic  fibers  have 
many  anastomoses,  with  the  resulting  crossing  and  mingling  of  both 
stimulating  and  inhibitory  impulses,  it  will  be  easily  understood 
how  difficult  it  is  to  bring  order  out  of  this  chaos,  and  to  isolate  the 
separate  threads  of  this  entangled  meshwork.  It  will  also  become 
evident  why  writers,  among  whom  I  may  mention  Stiller,  Rosen- 
thal, and  Oser,f  have  endeavored  to  establish  the  manifold  manifes- 
tations of  the  disturbed  innervation  of  the  organ  upon  a  basis  cor- 

*  Occnrsus  mediei  de  vaga  aegritudine  infirmitatis  nervorum  Andreas  Com- 
paretti.    Venetiis,  1790. 

•f-  Stiller.  Die  nervosen  Magenkrankheiten.  Stuttgart,  1884. — Rosenthal.  Ma- 
genneurosen  und  Magenkatarrh.  Wien,  1886. — Oser.  Die  Neurosen  des  Magens 
und  ihre  Behandlung.     Wiener  Klinik,  1885. 

473 


474 


DISEASES   OF  THE  STOMACH. 


responding  to  our  present  knowledge  of  its  physiology.  Yet  even 
to  this  day  our  knowledge  is  so  limited  end  vague  that  conjecture 
and  hypothesis  still  play  a  prominent  part,  while  the  actual  clinical 
facts  upon  which  our  pathology  is  based  fill  only  a  very  small  space. 
How  easily,  then,  can  we  speculate  as  to  the  probable  causes  and 
refer  everything  to  higher  centers  of  innervation — e.  g.,  Kosenthal's 
hunger  center,  for  which  we  may  bring  as  many  arguments  jyro 
as  contra. 

Classification. — The  neuroses  of  the  stomach  may  arise  either 
directly  from  diseases  of  this  viscus,  or  they  may  be  caused  reflexly 
from  other  organs — the  brain,  spinal  cord,  uterus,  kidneys,  liver, 
etc. ;  thus  the  gastric  nervous  centers  may  be  called  into  action, 
either  directly  or  reflexly.  Yet,  in  the  majority  of  cases,  as  Oser 
has  shown,  a  sharp  distinction  can  not  be  made ;  as  an  example  he 
cites  the  so-called  reflex  cardialgias  in  uterine  disorders  wliere  both 
affections,  the  uterine  and  the  gastric,  might  be  considered  concur- 
rent, as  well  as  standing  in  a  causal  relation  to  each  other. 

In  the  following  table  of  the  various  neuroses  I  have  followed  a 
classification  which  is  midway  between  the  purely  symptomatic  and 
the  etiological,  in  order  that  a  better  general  idea  might  thus  be  ob- 
tained. 

THE  NEUROSES   OP   THE  STOMACH. 


a.  Sensory. 
HyperaBsthesia. 
Nausea. 
Hyperorexia. 
Anorexia. 
Parorexia. 
Gastralgia. 

Anaesthesia. 
Polyphagia. 


II. 


Gastro-intestinal  neu- 
rasthenia (dyspepsia 
nervosa. 


Conditions  of  Irritation. 
b.  Secretory. 
Hyperchlorhydria. 
Hypersecretion. 
(Gastrosuccorhcsa.) 


Conditions  of  Depression. 
Anachlorhvdria. 


III.  Mixed  Form. 
Anorexia  mentalis. 


c.  Motor. 
Eructation. 
Pyrosis. 
Vomiting. 
Hyperkinesis, 
Colic. 
Tormina  Tentriculi. 

Atony  or  hypokinesis. 
Insufficiency  of  the 

pylorus  and  cardia. 
Rumination, 

Gastroptosis  and  en- 
teroptosis. 


IV.  Reflexes  from  other  Organs  upon  the  Gastric  Nerves. 
Reflexes  from  the  brain,  spinal  cord,  kidneys,  liver,  sexual  organs,  and  intestines 
manifest  themselves  in  the  forms  mentioned  in  I  and  II. 


OCCURRENCE  AND  ETIOLOGY  OP   GASTRIC  NEUROSES.     475 

Taken  all  in  all,  tlie  above  classification,  which  has  since  been 
adopted  by  other  writers,*  will  suffice.  However,  in  view  of  the 
very  varying  and  interchangeable  clinical  pictures  it  is  often  diffi- 
cult to  decide  how  some  are  to  be  classified.  Thus,  ought  rumina- 
tion to  be  grouped  among  the  atonic  or  irritative  hyperkinetic  pro- 
cesess  ?  Where  shall  mental  anorexia  be  placed  ?  etc.  Still,  this  is 
of  no  significance  when  compared  to  the  much  more  important  fact 
to  which  attention  has  already  been  drawn,  that  all  these  various  con- 
ditions rarely  occur  as  distinct,  independent  diseases,  but  usually  in 
groups,  either  appearing  simultaneously  or  closely  following  one 
another  during  the  course  of  the  malady,  passing  before  us  like  a 
panorama  with  ever-changing  scenes. 

Occurrence  and  Etiology. — To  prevent  needless  repetitions,  let  it 
be  said,  once  for  all,  that  these  conditions  occur  most  frequently  in 
women,  and  especially  in  the  younger  rather  than  those  further  ad- 
vanced in  years.  It  is  hardly  necessary  to  say  that  this  is  due  to 
the  greater  predisposition  of  women  to  the  functional  neuroses, 
and  to  their  great  frequency  before  the  climacteric  rather  than 
after  it.  In  both  sexes  the  middle  period  of  life,  from  about  the 
twentieth  year  onward,  is  most  frequently  the  time  of  their  occur- 
rence ;  they  are  less  common  before  this  time,  and  least  of  all  after 
the  fifties. 

No  such  general  rules  as  these  for  sex  and  age  can  be  formu- 
lated for  the  condition  of  these  patients.  Some  of  them  have  severe 
disturbances  of  nutrition,  are  feeble,  emaciated,  ansemic  persons,  with 
a  faded,  pale  complexion,  through  which  the  veins  may  be  seen ; 
they  have  languid  eyes,  a  weak  voice,  feeble  movements,  and  a 
dragging  gait ;  some  are  even  bedridden  ;  while,  on  the  other  hand, 
we  are  astonished  to  see  people  enter  our  offices  who  are  apparently 
healthy  and  vigorous,  and  with  red  cheeks,  yet  who  complain  of  a 
host  of  nervous  disturbances.  There  are  also  exceptions  to  the  well- 
known  rule,  that  the  people  attacked  with  the  gastric  neuroses  are 
usually  those  who  live  in  large  cities,  and  especially  those  better 
situated,  whose  struggle  for  existence  demands  an  especial  expendi- 

*  Similar  classifications  have  been  published  ;  for  example,  by  Garland,  Gastric 
Neurasthenia,  Boston  Medical  and  Surgical  Journal,  October  3,  1889;  Cimbali,  Le 
maladie  nervosa  dello  stomaco,  Morgagni  1,  1891. 


476  DISEASES  OF   THE  STOMACH. 

ture  of  labor  and  mental  excitement  to  keep  up  witli  tlie  demands 
of  an  "  advanced  culture."  I  have  seen  quite  severe  neuroses  in 
persons  of  the  lower  classes — farmers,  working  people,  female  serv- 
ants, factory  girls,  and  finally,  where  one  would  least  expect  it,  in 
sailors. 

As  predisposing  factors,  it  is  not  difficult  to  recognize  the  rela- 
tions of  severe  mental  exertions  of  men  in  their  business  affairs,  and 
in  women  the  absolute  or  relative  excess  of  social  duties  and  pleas- 
ures; and  in  both  sexes  the  excessive  use  of  the  sexual  organs. 
For,  not  infrequently,  we  see  cases  of  periodically  recurring  neu- 
roses which  are  due  to  periodical  increase  of  these  causes,  inasmuch 
as  the  amount  of  work  and  of  pleasures  is  greater  at  some  times  and 
is  less  at  others ;  this  increase  and  diminution  is  accompanied  by  a 
corresponding  increase  or  lessening  or  even  disappearance  of  the 
nervous  symptoms.  Stiller  observed  an  exacerbation  of  the  neuroses 
in  some  of  his  patients  in  the  spring  ;  in  my  practice  the  majority  of 
these  patients  come  at  the  close  of  the  winter.  Yet,  as  the  patients 
usually  allow  some  time  to  elapse  before  consulting  a  physician,  this 
would  afford  very  little  information  as  to  the  origin  of  these  disor- 
ders ;  but  the  patients  themselves  frequently  assert  that  in  the  quiet 
season  they  feel  entirely  or  relatively  well. 

Almost  without  exception  these  patients  have  symptoms  of  gen- 
eral neuroses  as  well  as  their  gastric  complaints ;  naturally  these  are 
often  not  well  marked,  or  are  not  considered  by  the  patient  to  be- 
long to  the  actual  trouble,  so  that  a  thorough  examination  may  be 
needed  to  bring  them  to  light.  We  may  then  discover  a  so-called 
nervous  temperament,  headaches  of  various  location  and  character, 
disinclination  toward  mental  exertion,  depression,  mental  sluggish- 
ness, poor  memory,  absence  of  mind,  vertigo  and  its  curious  mani- 
festation agoraphobia,  insomnia,  neuralgias  and  parasthesise,  espe- 
cially of  the  trigeminus  and  in  the  lower  extremities,  pupillary  dif- 
ferences, evidences  of  spinal  irritation,  intercostal  neuralgias,  vesical 
weakness,  and  ovarian  pains — all  of  these  manifestations  relegating 
such  patients  to  the  great  class  of  neurasthenics.  If  the  disturbances 
of  the  diseased  mind  are  projected  along  the  most  varied  nervous 
tracts — i.  e.,  forming  the  capricious  and  confusing  picture  of  hys- 
teria— another  and  almost  equally  frequent  class  of  cases  will  be 


HYPERESTHESIA  OP  THE  STOMACH.  477 

grouped.  ISTaturally,  it  is  impossible  in  every  case  to  draw  a  sharp 
line  between  neurasthenia  and  hysteria.  The  marked  cases  of  each 
are  easily  recognized,  but  there  is  a  border  province  in  which  the 
judgment,  I  would  like  to  say  the  tact,  of  the  physician  must  decide 
the  diagnosis.  For  the  present  it  is  sufficient  to  know  that  the 
neuroses  of  the  stomach  are  usually  (although  not  always)  only  a 
partial  manifestation  of  general  nervousness  in  the  broadest  sense  of 
the  word — i.  e.,  of  neurasthenia  and  hysteria ;  the  very  important 
deduction  from  this  fact  is,  that  the  main  object  of  the  treatment  is 
to  cure  the  primary  affection,  and  is  not  to  he  directed  only  to  a 
single  symjptom,  however  prominent.  This  will  impart  an  almost 
uniform  character  to  the  therapeutic  measures  for  these  troubles, 
and  hence  the  essential  features  of  the  treatment  will  always  be  the 
group  of  nervines,  including  both  medical  and  dietetic  measures.  I 
shall  therefore  consider  the  treatment  of  the  gastric  neuroses  col- 
lectively at  the  close  of  this  subject  (page  548). 

I.    Conditions  of  Ieeitation. 

Proceeding  from  these  general  considerations  to  the  special,  I 
will  first  mention  the  mildest  disturbances  of  sensation,  hypersesthesia 
of  the  stomach,  which  manifests  itself  in  a  feeling  of  fullness  and 
tension  as  well  as  oppression  in  this  region,  and  nausea.  These  sen- 
sations are  so  closely  allied  to  the  normal,  and  are  the  daily  and  con- 
stant accompaniments  of  so  many  digestive  disturbances,  that  they 
include  the  entire  series  of  gastric  disorders,  from  the  "  full  stom- 
ach "  after  a  good  dinner  and  the  symptoms  of  intoxication  after  a 
strong  cigar,  up  to  the  incessant  oppression  and  fullness  in  the  epi- 
gastrium felt  by  many  patients  with  cancer,  the  burning  sensation 
in  the  abdomen,  and  nausea  which  may  accompany  hysteria,  menin- 
geal irritation,  cerebral  tumors,  and  other  diseases  of  the  central 
nervous  system.  As  concomitant  manifestations  of  other  diseases 
they  must  be  disregarded  here,  for  I  must  limit  myself  to  the  gen- 
uine neuroses.  But  it  is  difficult  to  define  the  latter  exactly,  to 
recognize  these  symptoms  as  such — in  other  words,  to  group  them 
as  hypersesthesise  of  the  stomach. 

Positive  information  can  only  be  obtained  after  a  careful  and 
thorough  examination  with  all  the  mecmsfor  the  differential  diag- 


478  DISEASES  OF  THE  STOMACH. 

nosis  of  the  'various  organic  gastric  disorders.  Furthermore,  one 
must  not  forget  that  many  patients,  either  through  carelessness  or 
because  they  locate  falsely,  attribute  many  painful  sensations  to  the 
stomach,  which  really  do  not  exist  there,  but  in  the  epigastrium  (the 
so-called  epigastric  pain  of  Briquet,  myalgia  of  the  abdominal  mus- 
cles) ;  such  pains  are  usually  the  result  of  cutaneous  hyperaesthesia 
or  muscular  rheumatism,  or  may  even  proceed  from  the  spinal  col- 
umn. That  the  greater  number  of  patients  observe  themselves  very 
carelessly,  and  are  very  reckless  in  localizing  painful  sensations,  is 
a  daily  experience ;  hence  the  patient  must  not  alone  describe  the 
painful  spot,  but  he  must  also  point  it  out  to  me.  Oser  has  fre- 
quently seen  sufferers  from  locomotor  ataxia  who  referred  the  site 
of  their  troubles  to  the  stomach,  although  they  did  not  suffer  from 
gastric  crises ;  they  had  mistaken  the  girdle  sensation  perceived  in 
the  epigastrium  for  gastric  sensations. 

The  knowledge  of  hypersesthetic  conditions  of  the  mucous  mem- 
brane of  the  stomach  is  very  old.  Todd  *  cites  examples  from  Hip- 
pocrates and  Aretseus  ;  Schmidtraann  f  and  Barras :{:  knew  of  them 
— the  latter,  strange  to  say,  under  the  name  of  dyspepsia.  Pember- 
ton  considered  it  a  condition  of  muscular  irritability.  J.  Johnson 
describes  it  as  a  "  morbid  sensibility  of  the  stomach  "  ;  while  Todd 
cites  cases  under  the  name  of  "  irritable  gastric  dyspepsia." 

The  characteristic  feature  of  hypersesthesia  is  an  increased  irri- 
tability of  the  stomach,  the  result  of  which  is  that  the  gentlest  irri- 
tants, including  even  those  which  are  normal,  may  call  forth  very 
painful  sensations  ;  the  latter  may  sometimes  occur  even  without 
the  presence  of  such  direct  irritants.  And  yet  these  same  sensory 
nerve-endings  in  the  mucous  membrane  of  the  stomach  are  other- 
wise so  tolerant !  When  well,  we  know  nothing  of  the  existence 
of  the  stomach,  and  much  less  of  its  functions  ;  but  in  these  patients 
there  is  a  continuous  sensation  of  heat  or  cold,  gnawing,  pulling, 
burning  in  the  organ,  which  may  exert  such  a  powerful  influence 
on  the  physical  and  mental  life  of  the  patients  that  every  sensation. 


*  Loc.  cit.,  p.  633. 

f  J.  Schmidtmann.    Summa  observationum  raedicarum  ex  praxi  clinica  triginta 
annorum.     Berolirii,  1819-1826. 

X  Barras.     Traite  sur  les  gastralgies  et  enteralgies.     Paris,  1837. 


HYPERESTHESIA  OF  STOMACH.  479 

and,  in  fact,  anything  which  attracts  their  attention,  is  considered 
in  its  relations  to  their  stomachs.  "  Le  principe  de  tons  mes  maux 
est  dans  nion  ventre  ;  il  est  tellement  sensible,  que  peine,  doulenr, 
plaisir,  en  un  mot  toute  espece  d' affections  morales  ont  la  leur  prin- 
cipe. Je  pense  par  le  ventre  si  je  pnis  m'exprimer  ainsi."  This 
is  what  a  lady  wrote  to  Pinel ;  it  is  a  splendid  description  of  a 
condition  which  has  been  called  hypochondria  ;  at  all  events,  it  is 
located  in  the  hypochondrium,  but  it  undoubtedly  also  belongs  to 
the  hypergesthetic  conditions  of  the  stomach. 

The  nervous  nature  of  these  disturbances  is  also  shown  by  the 
fact  that,  in  some  cases,  taking  food  moderates  them ;  but  they 
may  become  worse  after  the  stomach  has  again  become  empty  ;  how- 
ever, in  the  majority  of  cases  the  reverse  is  true,  and  the  trouble  is 
aggravated  during  digestion.  Sometimes  the  sensations  described 
above  appear  only  after  taking  even  very  small  amounts — as,  for 
example,  a  glass  of  water.  Then  everything  which  has  been  taken 
is  vomited,  and  remedies  which  are  usually  well  borne  now  cause 
severe  pain,  clammy  sweats  due  to  fear,  and  even  convulsions  and 
collapse  ;  mild  aperients  may  be  followed  by  severe  diarrhoea. 

Sometimes  the  hypersesthesia  is  preceded  by  a  tangible  cause. 

Thus,  for  example,  it  sometimes  follows  chloroform  narcosis.     Such 

a  case  I  have  recently  seen  : 

A  young  woman,  twenty-eight  years  old,  suffered  from  tabes,  and  also 
had  a  carcinoma  of  the  anterior  lip  of  the  os  uteri ;  the  latter  was  removed 
under  narcosis.  Before  the  operation  her  appetite  and  digestion  were 
excellent.  For  three  days  after  she  remained  in  a  condition  in  which 
she  complained  of  severe  burning  in  the  stomach  and  an  unquenchable 
thirst ;  everything  she  ate  was  vomited  after  a  short  time.  Several  times 
on  the  day  after  the  operation  I  examined  the  vomit,  which  consisted  of 
weak  coffee,  and  always  found  hydrochloric  acid  in  it.  Small  pieces  of 
ice,  morphine  injections,  and  large  doses  of  morphine  and  cocaine  inter- 
nally were  useless.  The  vomiting,  which  was  never  spontaneous,  ceased 
only  a  few  days  before  death.  Peritonitis,  which  had  been  suspected  to 
be  the  cause  of  the  obstinate  vomiting,  was  not  found  at  the  autopsy. 

For  a  similar  case  I  am  indebted  to  Dr.  Steyerthal,  of  Bruel : 

B.,  nineteen  years  old,  of  a  large  and  powerful  build,  had  always  en- 
joyed good  health  until  about  six  weeks  previously,  when  he  began  to 
complain  of  severe  pains  in  the  left  hip,  which  were  said  to  have  set  in 
after  a  wound  of  the  foot  which  he  had  received  while  skating.  As  ex- 
tension did  not  relieve  the  pains,  resection  of  the  hip  joint  was  decided 


480  DISEASES   OF  THE  STOMACH. 

upon.  The  pains  were  so  agonizing  tliat  transportation  to  the  hospital 
was  only  possible  under  chloroform  narcosis.  On  February  6,  1889,  the 
operation  was  performed.  Only  a  very  slight  caries  was  found  in  the 
joint ;  no  osteomyelitis.  The  prolonged  chloroform  narcosis  was  well 
borne.  On  February  7th,  without  any  cause,  the  patient  began  to  vomit 
all  the  food  and  drink  which  he  took.  Morphine,  ice,  antifebrine,  and 
antipyrin  had  no  effect.  The  vomiting  continued  until  his  death,  shortly 
after  midnight  on  February  8th.  The  autopsy  on  February  10th  showed 
that  all  the  organs  were  absolutely  normal  excepting  a  marked  dilatation 
of  the  stomach.  There  was  no  peritonitis.  Chemical  analysis  of  the 
chloral-chloroform  which  had  been  used  showed  it  to  be  absolutely  pure. 

In  these  cases  there  was  an  acute  irritation,  which  could  only  have 
arisen  from  the  nerves ;  here  its  origin  was  central.  In  the  chronic 
form  the  same  may  be  true  of  a  number  of  the  above-mentioned 
disorders,  while  in  others  the  seat  of  the  irritation  is  peripheral. 
Among  the  causes  given  is  insufficient  food  for  a  long  period,  or 
sudden  restriction  of  diet ;  thus,  prolonged  fasting  is  said  to  have 
caused  hypersesthesise  of  the  stomach  in  Catholic  priests,  fakirs,  and 
Brahmans ;  excesses  and  an  enfeebled  bodily  condition  are  said  to 
favor  their  development.  On  the  other  hand,  more  material  causes 
are  also  given,  as,  for  example,  gastric  calculi,  the  well-known  con- 
cretiones  benzoarticse,*  and  worms.  In  many  cases  the  causal  fac- 
tors will  be  sought  for  in  vain.  Thus,  I  have  recently  had  under  my 
treatment  a  strong  man,  in  good  circumstances,  thirty  years  old,  who 
has  developed  this  condition  ;  as  yet  I  can  discover  no  cause  for  it, 
with  the  possible  exception  of  a  transient  gastric  catarrh. 

Idiosyncrasies  may  also  be  included  among  the  hypersesthesise. 
As  is  well  known,  the  eating  of  certain  foods  by  predisposed  indi- 
viduals is  followed  by  peculiar  sensations  in  the  epigastrium,  mild 
oppression  or  burning,  and  sometimes  vague  nausea,  combined  with 
singular  excitation  of  the  cutaneous  nerves,  pruritus,  erythema,  and 
the  formation  of  wheals  [urticaria]  ;  even  headache  and  shght  febrile 
movements  which  either  soon  disappear  of  themselves,  or  are  sub- 
dued by  the  strong  reflex  irritants  from  the  gastric  mucous  mem- 
brane, as  strong  wines,  cognac,  and  the  like.  This  condition  most 
frequently  follows  the  eating  of  shellfish,  crabs,  lobsters,  oysters,  etc., 

*  [These  are  of  very  frequent  occurrence  in  the  abomasum,  or  fourth  stomach  of 
ruminants.  See  Lancet,  1888,  vol.  i,  p.  186.  For  hair  tumors  of  the  stomach,  etc., 
vide  supra,  p.  376. — Ed.] 


IDIOSYNCRASIES   OF   THE   STOMACH.  481 

sometimes  also  strawberries,  or  green  peas.  Here  we  are  surely  not 
dealing  with  a  psychosis,  Lut  only  with  an  abnormal  sensitiveness 
of  the  gastric  nerves  toward  these  articles  of  food ;  for  its  first 
occurrence  is  purely  accidental,  and  it  recurs  after  these  conse- 
quences have  long  since  been  forgotten. 

A  very  peculiar  condition  which  may  also  be  inchicled  among-  the 
idiosyncrasies  was  recently  observed  by  nie  in  a  man,  fifty-one  years  old, 
in  whom  "  the  smallest  quantities  of  fat "  caused  severe  migraine,  tempo- 
rary partial  amaurosis  (Flimmerscotom),  flatulence,  and  the  passage  of 
watery  and  very  offensive  stools.  This  condition  was  said  to  occur  twelve 
to  fourteen  hours  after  taking  fatty  food ;  the  expression  "  fatty  "  is  ob- 
viously very  vague,  and  I'efers  only  to  the  more  or  less  oily  additions  to 
the  ordinary  articles  of  food.  It  was  characteristic  of  a  neurosis  that  he 
could  eat  pure  table  butter  without  any  inconvenience,  but  as  soon  as  he 
had  tasted  butter  which  bad  been  rendered  the  peculiar  attacks  came  on. 
Otherwise,  this  patient,  who  moved  in  the  best  society,  had  a  good  appe- 
tite, was  robust,  and  had  no  real  gastric  disturbances.  In  the  intervals 
between  the  attacks  the  bowels  were  regular.  In  order  to  remove  every 
suspicion  of  an  insufficient  decomposition  or  absorption  of  the  fats,  the 
passages  were  examined  on  three  different  occasions  after  an  attack,  and 
the  amount  of  fat  was  ascertained  by  meaus  of  extraction  with  ether ;  but 
the  amount  was  always  found  normal  in  comparison  to  the  small  quantity 
of  fat  which  he  consumed.  The  patient  had  suffered  from  this  trouble  for 
years,  was  himself  convinced  that  he  was  "  very  nervous,"  and  had  de- 
rived no  benefit  from  living  in  the  mountains  or  at  the  seashore,  nor 
from  drinking  the  waters  at  Carlsbad  and  Kissingen,  nor  from  the  use  of 
preparations  of  pancreatin  aud  the  like. 

The  deviations  from  the  feeling  of  hunger  constitute  a  second 
series  of  sensations  which  become  pathological  by  a  gradual  increase 
of  those  which  were  originally  normal.  As  is  well  known,  the 
length  of  time  during  which  one  can  endure  hunger,  or,  to  express  it 
more  properly,  during  which  one  need  not  eat  anything,  is  subject 
to  very  extraordinary  variations.  Some  people  are  satisfied  with 
two  meals  a  day,  a  good  breakfast  and  a  substantial  dinner  at  6  or 
7  p.  M. ;  while  others  must  eat  every  three  or  four  hours.  Unless 
this  is  done  they  experience  the  sensation  of  emptiness  of  the  stom- 
ach, and  faintness,  which  may  even  reach  such  a  degree  in  nervous 
persons  that  they  lose  consciousness ;  the  French  call  this  defailli- 
ance.  I  have  treated  a  state  official  who  was  utterly  unable  to  take 
even  a  glance  at  a  newspaper  unless  he  had  had  his  breakfast  ex- 
actly at  his  regular  time. 

An  exaggeration  of  this  condition  is  bulimia  (o  Xt/A09,  hunger, 


482  DISEASES  OP  THE  STOMACH. 

o  /3ov<;,  ox  '^) ;  it  is  also  called  cynorexia  [6  kvcov,  dog,  rj  ope^i^,  de- 
sire],  or  fames  canina ;  hyperorexia,  Heisshimger  or  Wolfshunger. 
Sometimes  this  condition  is  only  temporary  and  quite  closely  allied 
to  the  normal  sensations ;  at  other  times  it  is  permanent ;  in  the 
latter  it  constitutes  a  very  obstinate,  weakening,  and  exceedingly 
unpleasant  malady. 

It  may  occur  alone  or  may  be  a  symptom  of  the  various  diseases 
of  the  nervous  system,  naanifest  diseases  of  the  brain,  hysteria,  neu- 
rasthenia, and  psychoses ;  it  may  also  complicate  constitutional  dis- 
orders like  diabetes  and  Addison's  disease,  and  may  be  of  temporary 
duration  in  convalescence  from  acute  diseases,  after  serious  opera- 
tions, profuse  loss  of  fluids,  peripheral  irritation,  for  exam23le, 
worms  (Pavy),  uterine  disorders,  and  even  syphilis.  ISTaturally,  the 
most  interesting  cases  are  those  in  which  it  occurs  as  an  independ- 
ent disease. 

Potton  t  reports  the  case  of  an  hysterical  girl,  eighteen  years  old,  who 
ate  eleven  to  twelve  times  a  day,  and  consumed  10  to  12  kilogrammes  [22 
to  26i  pounds].  She  drank  little,  and  her  sleep  was  frequently  disturbed 
to  satisfy  the  craving  for  food.  The  stools  were  never  diarrhoeal,  but 
were  frequent  and  copious  ;  the  urine  was  negative.  The  patient  gained 
in  weight,  but  her  strength  began  to  fail.  A  cure  was  effected  with  in- 
creasing doses  of  morphine,  up  to  0"4  gramme  [gr.  vj]  in  twenty-four 
hours.  In  a  similar  case  morphine  was  useless,  but  it  was  cured  by  large 
doses  of  opium,  up  to  3  grammes  [gr.  xlv]. 

Peyer  I  describes  the  case  of  a  woman,  thirty-two  years  old,  who  was 
suddenly  seized  with  a  furious  attack  of  bulimia,  so  that  she  could  not  re- 
turn home  from  the  house  of  a  neighbor  whom  she  happened  to  visit.  In 
forty-five  minutes  she  ravenously  devoured  three  pints  of  milk,  twenty- 
three  eggs,  and  two  pints  of  strong  wine  which  Peyer  allowed  her  to  take. 
Thereupon  she  became  quieter,  went  to  sleep,  and  awoke  perfectly  well  on 
the  next  day.  She  described  the  attack  as  a  feeling  of  hunger  accom- 
panied by  an  inexpressible  pain  and  suffering  in  the  region  of  the  stom- 
ach ;  she  feared  that  she  would  die ;  she  did  not  feel  that  the  food  reached 
the  stomach,  and  it  did  not  relieve  her  condition ;  it  was  only  the  strong 
wine  which  affected  her. 

The  attack  had  been  preceded  by  severe  psychical  excitement  and 
worry. 

*  This  etymology  is  according  to  Roth-Gessler's  Klinische  Terminologie.  Er- 
langen,  1884. 

t  Potton.  ]&tudes  et  observations  sur  la  boulimie  dyspeptique.  Gaz.  med.  de 
Lyon,  juin  1,  1863. 

X  A.  Peyer.  Beitrag  zur  Kenntniss  der  Neurosen  des  Magens  und  des  Darras. 
Correspondenzblatt  schweiz,  Aerzte,  1888,  No.  30. 


BULIMIA.  483 

For  many  years  I  had  under  my  treatment  a  young  lawyer,  the  picture 
of  health,  normal  in  every  respect,  both  mentally  and  bodily,  but  who 
was  annoyed  with  continually  recurring-  attacks  of  bulimy.  He  was  at- 
tacked whenever  he  had  not  eaten  anything  for  two  or  at  most  three 
hours,  especially  in  the  morning,  when  he  was  frequently  aroused  from 
his  sleep.  He  was  then  utterly  unfit  to  attend  to  any  business,  not  even 
to  follow  a  conversation.  His  whole  existence  and  every  thought  con- 
centrated itself  on  the  immediate  allaying  of  his  ravenous  appetite.  A 
few  morsels  or  a  swallow  of  strong  wine  sufficed  temporarily,  but  soon 
the  torment  returned  with  renewed  vigor.  The  intervals  were  longest 
after  severe  bodily  exertion,  so  that  he  suffered  little  during  his  service 
in  the  army.  But  a  sedentary  occupation  caused  the  attacks  to  be  very 
severe,  and  so  annoying  that  the  patient  for  months  subjected  liimself  to 
all  kinds  of  treatment,  including  faradization  of  the  stomach,  systematic 
lavage,  etc. ,  but  unfortunately  all  without  any  visible  effect ;  the  best  re- 
sult was  obtained  with  large  doses  of  bromide  of  potassium,  but  even  this 
was  only  temporary. 

Rosenthal  gives  other  examples  associated  with  migraine,  hypo- 
chondria, and  exophthalmic  goitre.  The  disorder  also  accompanies 
diseases  of  the  brain.  Thus,  this  author  describes  a  case  which  oc- 
curred with  cerebral  embolism  subsequent  to  mitral  insufficiency 
and  cardiac  hypertrophy.  In  another  case  it  was  the  result  of  con- 
cussion of  the  brain ;  it  appeared  after  the  acute  symptoms  had  dis- 
appeared, and  lasted  about  three  months. 

Analogous  to  bulimia  are  the  cases  of  perverted  appetite  which 
occur  in  pregnancy,  children,  and  mental  disorders. 

Guipon  *  considers  bulimia  to  be  an  abnormal  increase  of  the 
digestive  powers,  which,  in  spite  of  the  increased  consumption  o£ 
food,  is  unable  "  to  repair  the  deficit  in  the  economy." 

As  I  have  already  said,  I  do  not  think  it  advisable  to  enter 
into  speculations  about  the  site  of  this  and  other  neuroses,  in  so  far 
as  the  more  exact  localization  is  concerned.  That  we  are  dealing 
with  central  and  not  peripheral  causes  is  proved  by  the  simple 
fact  that  any  trifle  which  is  introduced  into  the  stomach — a  piece 
of  bread,  a  cake,  a  swallow  of  wine— may  momentarily  assuage 
the  voracious  hunger;  yet  simple  appeasing  of  the  hunger  is 
out  of  the  question ;  and,  furthermore,  the  f eehng  may  come  on 
when  the  stomach  still  contains  large  quantities  of  food.     This  is 


*  Guipon.     Des  dyspepsies  boulimiques  et  syncopales.     Bull,  de  therap.,  1864, 
15  aout. 


484:  DISEASES  OP  THE  STOMACH. 

also  corroborated  by  tlie  cases  already  cited,  in  wbicb  tbe  malady 
followed  severe  cerebral  injury. 

The  cases  already  narrated  sbow  tbat  tbere  are  acute  and  chronic 
forms  of  bulimia ;  but  the  chief  difference  between  them  is  that  in 
the  latter  the  attacks  are  less  severe,  and  may  extend  over  weeks, 
months,  and  even  years. 

Under  these  conditions,  one  would  imagine  that  the  stomach  is 
abnormally  rapidly  evacuated,  and  that  this  is  the  cause  of  the  feel- 
ing of  hunger ;  but  in  a  tj^ical  case  of  bulimia  reported  by  Leo,* 
which  I  had  an  opportunity  of  observing  for  some  time  at  the  Au- 
gusta Hospital,  on  repeated  examinations  fifty  to  ninety  minutes 
after  the  test  breakfast,  and  more  abundant  meals,  the  stomach  was 
by  no  means  found  empty,  but,  instead,  the  amount  of  stomach  con- 
tents which  could  be  expressed  was  normal.  On  the  other  hand, 
in  a  woman  under  my  care,  who  for  some  time  was  awakened  every 
two  hours  during  the  night  to  satisfy  her  ravenous  appetite,  the 
stomach  was  found  almost  empty  thirty  to  forty-five  minutes  after 
the  test  breakfast ;  the  salol  test  was  decidedly  hastened,  the  reaction 
being  present  within  thirty  minutes,  and  very  marked  after  forty- 
five  minutes.  These  two  cases  simply  prove  that  there  is  no  uni- 
form condition  in  this  respect.  But  the  first  case  mentioned  shows 
how  easily  such  conditions  may  become  aggravated  if  the  patient  is 
at  all  liable  to  psychical  changes ;  for  within  a  few  months  he  was 
attacked  with  acute  insanity,  and  committed  suicide.  I  have  ob- 
served another  case  of  bulimia  in  a  man  with  sexual  perversion. 

Anorexia  {rj  ope^i^i,  the  desire)  denotes  a  lack  of  appetite  or  a  re- 
pugnance toward  food.  These  two  conceptions  do  not  correspond 
exactly,  since  it  is  one  thing  for  a  person  not  to  have  any  appetite, 
or  not  to  feel  hungry  ;  it  is  something  else  if  there  is  a  repugnance 
toward  food,  or  even  nausea  at  the  sight  of  it.  Yet  the  latter  may 
be  regarded  as  an  exaggeration  of  the  former,  and  therefore  they 
may  be  included  under  the  same  term. 

Anorexia  accompanies  nearly  every  dyspeptic  condition,  but 
naturally  the  discussion  of  this  variety  of  it  is  out  of  place  when 
speaking  of  the  gastric  neuroses.     In  the  latter,  the  loss  of  appetite 

*  Leo.    Verhandlungen  des  Vereins  fiir  innere  Med.     Berlin,  1889. 


BULIMIA.  485 

may  arise  spontaneously,  or  may  be  due  to  hypergesthesia  of  the 
stomacli ;  lience,  central  or  peripheral  conditions  of  irritation  may 
be  among  its  causes. 

Both  combine  to  produce  their  effects :  the  original  anorexia, 
due  to  a  cerebral  lesion,  and  the  consequent  disturbance  of  nutri- 
tion, may  cause  hypersesthesia  of  the  stomach ;  and,  on  the  other 
hand,  the  latter  may  produce  changes  in  the  psychical  processes. 

We  may  therefore,  as  has  been  proposed  by  several  writers, 
make  a  distinction  between  mental  and  nervous  anorexia ;  in  the 
former  the  primary  factor  is  an  abnormally  irritable  condition  of 
the  mind ;  in  the  latter  the  primary  irritation  is  in  the  gastric  nerves, 
which  is  reflected  inward  toward  the  central  nervous  system.  But 
a  sharp  distinction  is  hardly  feasible,  and,  moreover,  both  of  these 
conditions  frequently  develop  into  gastric  neurasthenia,  a  neurosis 
which  will  be  discussed  later  on. 

Furthermore,  a  vicious  chain  is  formed,  which  may  at  times  lead 
to  the  most  serious  consequences.  In  the  first  place,  a  perverted 
taste  may  be  manifested  in  a  lack  of  desire  for  food,  which 
may  at  first  be  overcome  by  an  effort  of  the  will,  but  may  later 
develop  into  a  decided  repugnance  and  disgust  toward  food,  and  an 
almost  absolute  refusal  to  take  nourishment.  Frequently  such  pa- 
tients sit  down  at  the  table  with  a  good  appetite,  or  may  even  be 
very  hungry ;  yet  the  first  bite  is  followed  by  an  insuperable  aver- 
sion toward  eating  any  more.  In  other  cases,  absolutely  no  need  of 
taking  food  is  experienced.  "  Unless  I  saw  how  other  people  ate, 
and  were  I  not  compelled  to  go  to  meals,  I  would  not  feel  any  need 
of  it,"  is  a  frequent  complaint  of  these  patients.  They  would  like 
to  eat,  but  every  morsel  causes  them  pain.  If  hungry,  there  is  an  un- 
bearable sweetish  taste  in  the  mouth,  but  if  they  eat  they  are 
annoyed  by  a  sharp,  burning  sensation.  On  the  tongue  we  may 
frequently  see  smooth,  bright  red  insular  areas,  or  it  is  traversed  by 
deep  fissures,  giving  it  the  appearance  of  a  recently  plowed  field. 
The  organ  seems  to  be  too  large,  and  causes  the  patient  to  swallow 
incessantly.  Small  vesicles,  or  loss  of  the  epithelium  on  the  edges, 
cause  the  patients  much  annoyance,  and  make  them  fear  that  a 
cancer  is  developing.  ]!^umbness,  or  loss  of  sensation,  burning,  or 
dryness,    are   frequently   complained   of,    although   the   tongue   is 


486  DISEASES  OF  THE  STOMACH. 

smootli  and  moist.  Frequently  it  seems  to  be  bluist.  white,  as  if 
coated,  but  in  reality  it  is  only  anaemic.  In  otlier  cases  we  see 
peculiar  linear  liypertropby  of  tlie  epithelium,  giving  the  tongue  the 
appearance  of  a  cornfield.  In  one  of  my  cases  this  hairy  layer 
exfoliated  from  time  to  time,  and  then  gradually  reappeared.  Mi- 
croscopical examination  showed  that  there  was  an  epithelial  prolif- 
eration similar  to  what  has  been  described  as  "  black  tongue."  *  It  is 
inevitable  that  the  nutrition  suffers  from  this,  and  also  that  the  gastric 
mucosa  becomes  pathologically  irritable.  This  brings  us  to  the  end 
of  the  chain ;  but  then  the  hypersesthetic  mucous  membrane  revolts 
unless  the  brain  causes  it  to  refuse  nourishment.  We  may  be  con- 
tented if  these  patients  simply  emaciate  and  look  pale  and  miserable, 
provided  they  still  maintain  their  strength ;  but  in  the  severe  cases 
the  condition  of  inanition  may  become  very  threatening,  so  that  the 
patients'  feebleness  may  permanently  confine  them  to  bed. 

Marked  disquiet  and  restlessness,  which  struck  Fenwick  as  being 
very  inconsistent  with  the  emaciation  of  the  patients,  did  not  occur 
in  my  cases,  yet  at  times  this  may  constitute  a  very  prominent  fea- 
ture of  the  disease.  Fenwick  narrates  the  case  of  a  lady  whose  rest- 
lessness led  her  to  make  absolutely  unnecessary  railway  journeys, 
although  she  knew  that  these  would  be  followed  by  severe  exhaus- 
tion and  many  days'  confinement  to  bed. 

Hyperaesthesia  of  the  sensory  nerves  of  the  stomach  leads  to  the 
same  result,  but  in  the  opposite  way ;  for,  on  account  of  this  over- 
sensitiveness,  the  patients  gradually  eat  less  and  less  sohd  food. 
Finally,  the  general  nutrition  is  disturbed,  which  also  affects  the 
higher  centers.  Not  infrequently  this  condition  may  follow  pro- 
found mental  disturbances  of  a  depressing  nature,  so  that  patients 
who  had  previously  enjoyed  excellent  health  can  positively  trace  the 
beginning  of  their  affliction  to  a  definite  period,  sometimes  even  to 
the  very  day.  The  cause  may  be  the  death  of  a  dear  friend,  deep 
grief,  crosses  in  love,  loss  of  fortune,  disgust  toward  some  particular 
article  of  food,  an  unappetizing  dish,  etc.  Frequently  the  condition 
arises  without  any  discoverable  cause.    The  majority  of  these  patients 


*  Dirkler.     Ein  Beitrag  zur  Pathologie  der  sogen.  schwarzen  Haarzunge.    Vir« 
chow's  Archiv,  Bd.  cxviii,  p.  46. 


GASTRALGIA.  487 

consist  of  young  girls  of  the  Letter  classes ;  young  or  adult  men  are 
rarely  attacked.  As  chronic  anorexia  may  lead  to  marked  emacia- 
tion and  feebleness,  and,  as  Fen  wick  *  clauns,  even  to  death,  it  may 
be  mistaken  for  a  constitutional  disease,  especially  phthisis.  Such 
errors  are  frequently  made,  and  may  occur  very  readily,  because  the 
enfeebled  condition  of  these  patients  reduces  their  powers  of  resist- 
ance, and  they  may  therefore  be  easily  attacked  by  infectious  germs ; 
this  will  explain  their  predisposition  toward  pneumonia,  2Dleurisy, 
acute  bronchitis,  etc.  Hence  a  thorough  examination  of  the  heart 
and  lungs  is  very  important,  and  should  never  be  neglected.  On 
the  other  hand,  tuberculosis  develops  much  less  frequently  than  one 
would  expect.  I  have  now  observed  a  number  of  cases  of  severe 
nervous  anorexia  for  years ;  they  are  in  bed  during  the  greater  part 
of  the  year ;  there  have  been  fluctuations  in  the  general  condition, 
temporary  improvement,  either  spontaneously  or  after  a  sojourn  at 
the  spas,  or  during  some  new  course  of  treatment ;  but,  taken  all  in 
all,  the  condition  is  about  the  same,  without  any  definite  cure,  yet 
without  any  other  marked  complications.  We  may  dispose  of  such 
cases  under  the  generic  expression  of  "  hysteria,"  but  this  by  no 
means  alters  the  fact  that  it  is  a  sad  affliction  for  the  patients,  and 
especially  for  their  relatives. 

Gastralgia  or  Gastrodynia  f  (97  oSvvrj,  pain).  Although  the  causes 
of  pain  in  the  stomach  are  very  manifold,  yet  its  manifestation  is 
quite  uniform.  This  is  perfectly  rational,  because  the  pain  is  always 
due  to  an  irritation  of  the  sensory  fibers  of  the  vagus,  either  in  its 
peripheral  terminal  filaments  or  nucleus,  or  in  the  reflections  to  it 
from  still  higher  centers.  Hence  gastralgia  may  be  due  to  local 
causes,  or  to  conditions  of  irritation  in  the  nerves  outside  of  the 
stomach. 

The  attacks  of  pain  may  be  ushered  in  by  a  feeling  of  discom- 
fort, fullness  and  tension  in  the  epigastrium,  or  they  may  begin  sud- 
denly and  reach  their  greatest  intensity  almost  instantly.     I^ot  in- 

*  Fenwick.     On  Atrophy  of  the  Stomach  and  on  the  Nervous  Affections  of  the 
Digestive  Organs.     London,  1880,  p.  99. 

f  I  avoid  the  expression  cardialgia,  becaiise  it  localizes  the  pain  at  a  definite  spot 
in  the  stomach  without  our  being  able  to  prove  it. 
32 


488  DISEASES  OP  THE  STOMACH. 

frequently  the  scene  may  be  opened  with  a  copious  secretion  of 
saliva.  Oser  mentions  a  case  in  which  the  attacks  began  almost  uni- 
formly with  a  severe  toothache.  But  the  pain  in  the  left  ear,  which 
is  mentioned  by  this  author  among  the  initial  symptoms,  is  surely  to 
be  regarded  as  a  coincidence.  The  character  of  true  gastralgia  is  an 
agonizing  boring  or  cutting  pain,  sometimes  sharply  localized,  some- 
times diffuse,  or  even  resembling  a  girdle  sensation ;  in  severe  cases 
the  intensity  is  very  pronounced.  Instinctively  the  patients  double 
themselves  up  to  relax  the  abdominal  muscles,  breathe  superficially, 
and  carefully  avoid  coughing  and  speaking  aloud.  Although  there 
is  decided  cutaneous  hypersesthesia  of  the  abdominal  parietes,  yet 
deep  pressure  often  gives  relief.  The  face  is  pale,  distorted  with 
pain,  and  covered  with  cold  sweat,  and  there  may  be  conditions  of 
collapse  with  an  intense  sensation  of  impending  death,  and  attacks 
of  unconsciousness.  The  abdominal  aorta  pulsates  vigorously,  and 
pains  radiate  along  the  spinal  column  and  into  the  intercostal  spaces. 
At  times  points  of  exquisite  tenderness  may  be  demonstrated  along 
the  spinal  column  or  the  lumbar  nerves. 

In  its  general  features  and  duration  the  gastralgic  attack  is  very 
variable ;  the  paroxysms  may  be  either  brief  and  mild  or  may  last 
for  hours,  and  may  torture  the  sufferer  till  medical  aid  or  IS^ature 
brings  relief.  As  a  rule,  the  attack  wears  itself  out  and  the  normal 
condition  is  gradually  restored ;  at  other  times  it  terminates  sud- 
denly with  vomiting  ;  or  the  patient,  to  whom  every  morsel  would 
have  been  a  horror  only  a  short  time  before,  now  experiences  sharp 
hunger  and  demands  food  after  the  attack  is  over.  The  urine  passed 
after  the  paroxysm  usually  has  a  low  specific  gravity.  A  feeling  of 
marked  relaxation  and  exliaustion  is  left  behind.  Happily,  these  at- 
tacks do  not  recur  frequently,  yet  I  have  seen  a  case  in  which  there 
were  three  or  four  in  one  day,  causing  very  profound  exhaustion  of 
the  patient. 

The  etiology  of  gastralgia  is  very  varied,  and  may  be  classified  as 
follows : 

1.  Local  Causes  {true  gastralgia). — In  the  chapter  on  Gastric 
Ulcer  I  mentioned  the  fact  that  there  are  follicular  inflammations, 
haemorrhages,  and  losses  of  substance  of  the  mucous  membrane 
which  are  not  manifested  by  the  classical  symptoms  of  ulcer  of  the 


GASTRALGIA.  489 

stomach,  but  which  give  only  a  single  symptom,  recurring  gastralgia, 
which,  although  it  does  not  appear  after  every  meal,  yet  stands  in 
some  relation  to  taking  food.  Now,  it  is  characteristic  of  nervous 
gastralgia  that  it  has  nothing  at  all  to  do  with  eating ;  therefore, 
strictly  speaking,  these  cases  just  spoken  of  do  not  belong  here ;  yet 
we  must  not  classify  too  strictly  on  either  side,  because  every  experi- 
enced physician  has  seen  cases  in  which  these  criteria  could  not  be 
applied.     The  following  is  an  example  : 

Miss  Von  B.,  from  D ,  twenty-one  years  old ;  complained  of  gas- 

tralgic  pains  which  recurred  irregularly  for  about  six  months.  Some- 
times they  stay  away  for  weeks  ;  at  other  times  they  recur  every  few  days. 
A  relation  of  these  attacks  to  taking  food  was  at  times  suspected,  but  not 
constantly  present.  They  have  frequently  occurred  very  early  in  the 
morning,  and  have  aroused  her  from  sleep ;  the  pain  was  localized  in  the 
stomach  or  the  infrasternal  depression,  and  was  not  very  severe.  No  his- 
tory of  ulcer ;  never  had  migraine  ;  the  acidity  of  the  filtrate  after  the  test 
breakfast  was  66  per  cent — i.  e.,  just  at  the  upper  limits  of  the  normal ; 
contains  no  abnormal  constituents.  Physical  examination  negative.  No 
tenderness  over  the  ovaries,  no  painful  points  on  pressure.  Although 
the  patient  did  not  look  bad,  yet  recently  she  had  lost  constantly  in 
weight.  The  continuous  frequency  of  the  attacks  during  the  past  few 
weeks  led  her  to  come  to  Berlin  for  treatment.  Diagnosis :  follicular 
ulceration  of  the  mucous  membrane  of  the  stomach.    A  rest  cure  ordered. 

The  patient  left  the  sanitarium  after  four  weeks,  during  which  time 
she  had  gained  four  kilogrammes  [about  nine  pounds],  and  without  hav- 
ing had  any  attacks  during  the  last  fortnight.  Soon  after  she  was  mar- 
ried, and  according  to  subsequent  reports  has  remained  free  from  attacks 
ever  since. 

In  cases  like  the  above,  in  spite  of  the  apparently  idiopathic  gas- 
tralgia, there  are  distinct  anatomical  lesions.  There  is  another  group 
of  gastralgias  which,  although  distinctly  neurotic,  yet  are  only  indi- 
rect, since  the  real  lesion  is  a  neurosis  which  consists  in  hypersecre- 
tion of  gastric  juice,  concerning  which  I  will  speak  later.  It  is 
evident  that  the  very  acid  chyme  irritates  the  gastric  nerves  and 
thus  causes  typical  attacks  of  gastralgia,  for  which  no  other  cause 
than  this  can  be  found. 

Thus  the  class  of  genuine  gastralgias  is  restricted  to  a  very  small 
group.  My  own  experience  leads  me  to  be  very  sparing  of  the 
diagnosis  of  idiopathic  gastralgia,  and  I  believe  that  many  of  the 
cases  grouped  under  this  heading  would  be  differently  classed  if 
they  were  examined  according  to  our  modern  methods. 


490  DISEASES  OF  THE  STOMACH. 

2.  Gast/ralgias  due  to  Diseases  of  the  Central  Nervous  System. — 
Diseases  of  the  brain  are  manifestly  very  infrequently  accompanied 
by  pains  in  tile  stomach  ;  according  to  Rosenthal,  only  a  few  vague 
data  are  given  by  Kruckenberg.  They  are  much  more  frequent  in 
spinal  diseases.  The  gastric  crises  of  tahes  were  first  described  by 
Charcot,  and,  after  attention  had  been  drawn  to  them  by  this  dis- 
tinguished Trench  clinician,  they  have  frequently  been  discussed. 

Although  Delamare  *  (1866)  was  the  first  to  carefully  study  these 
attacks — for  analogous  cases  were  reported  by  GuUf  as  early  as 
1856 — yet  it  is  due  to  Charcot  and  his  school  that  the  existence  of 
the  affection  has  been  firmly  established,  and  it  is  therefore  no  more 
than  right  to  attach  his  name  to  the  gastric  crises.  I  can  not  resist 
the  temptation  to  give  Charcot's  classical  description  of  such  crises :  % 
"  Suddenly,  and  frequently  with  an  attack  of  fulgurating  pains,  the 
patient  complains  of  pains  which  begin  in  the  groins,  ascend  along 
both  sides  of  the  abdomen  to  the  epigastrium,  where  they  become 
fixed.  There  are  also  pains  between  the  shoulders,  which  radiate 
like  lightning  to  the  buttocks.  The  heart  action  is  rapid  and  forci- 
ble ;  but  there  is  no  rise  in  temperature.  At  the  same  time  there  is 
almost  uninterrupted  and  exceedingly  painful  vomiting  ;  the  vomit 
consists  at  first  of  food,  later  of  a  mucous  fluid,  which  is  sometimes 
mixed  with  bile  or  tinged  with  blood.  This  is  accompanied  by 
marked  nausea  and  vertigo,  as  well  as  by  cardialgic  pains  which  at 
times  reach  a  terrible  degree  of  intensity.  These  gastric  pains  may 
continue  almost  uninterruptedly  for  two  or  three  days.  They  may 
appear  at  the  very  beginning  of  the  disease,  and  then  belong  to  the 
so-called  preataxic  symptoms,  but  they  may  not  disappear  even 
when  the  disease  has  reached  its  full  development  with  complete 
ataxia." 

The  frequency  of  the  attacks  is  variable  :  sometimes  there  are 
long  free  periods,  and  the  occurrence  of  the  crises  is  irregular  ;  at 
other  times  they  recur  monthly,  weekly,  or  even  at  still  shorter  in- 

*  Delamare.  Des  troubles  gastriques  dans  I'ataxie  locomotriee.  These  de  Paris, 
1866. 

\  W.  Gull.     Cases  of  Paraplegia.     Guy's  Hospital  Reports,  1856,  p.  161. 

X  Charcot.  Lemons  sur  les  maladies  du  systems  nerveux,  1881,  tomes  i,  p.  261, 
et  ii,  p.  32. — Des  crises  gastriques  tabetiques,  etc.  Gazette  medic,  de  Paris,  1889, 
No.  39. 


GASTRALGIA.  491 

tervals  ;  they  may  even  seem  to  assume  a  certain  regular  type.  A 
characteristic  feature  is  the  sudden  transition  from  the  condition  of 
intense  pains  and  complete  cessation  of  all  the  functions  of  the  stom- 
ach to  one  of  absolute  comfort,  so  that  the  patients  ask  for  food  a 
short  time  after  the  close  of  the  crisis. 

Examination  of  the  stomach  contents  before,  during,  and  after 
the  attack  has  not  revealed  anything  which  is  characteristic,  since 
the  degrees  of  acidity  which  were  found  were  very  variable,  and 
stood  in  no  relation  to  the  course  of  the  crisis.  Having  made  nu- 
merous examinations  myself,  I  can  corroborate  these  facts,  which 
were  first  announced  by  Yon  Noorden.* 

[The  contents  of  the  stomach  during  gastric  crises  have  been  care- 
fully studied  by  Cathelineau,f  whose  results  agree  with  those  al- 
ready given.  The  vomit  varied  in  amount  from  800  to  2,600  c.  c. 
[f  ^  2Y  to  87]  in  the  twenty -four  hours.  Giinzburg's  and  the  biuret 
tests  were  always  positive.  After  a  test  breakfast  free  HCl,  ery- 
throdextrin,  and  peptones  were  present.  Hayem  and  Winter's  test 
showed  hyperchlorhydria.  During  the  crises  the  results  were  not 
so  constant,  but  free  HCl  was  always  present.] 

Their  clinical  existence  having  been  established,  the  pathological 
basis  was  found  to  consist  in  a  sclerotic  degeneration  of  the  vagus 
nucleus  or  the  vagus  trunk  ;  this  has  been  demonstrated  in  numer- 
ous recent  papers  by  Kahler,  Demange,  Landouzi  and  Dejerine, 
Oppenheim,  and  others. 

In  the  course  of  time  I  have  seen  quite  a  large  number  of  cases 
of  gastric  crises  in  tabes.  The  diagnosis  is  readily  made  as  soon  as 
the  symptoms  of  locomotor  ataxia  are  well  marked.  But  if  the  crises 
are  among  the  initial  symptoms  we  may  be  in  doubt  for  a  long  time, 
and  it  is  possible  that  the  only  valuable  symptoms  present  may  be 
changes  in  the  pupils,  or  Westphal's  symptom,  anaesthesia  of  the 
pharynx,  etc.  Thus  it  may  happen  that  a  patient  who  originally 
consulted  us  on  account  of  a  "  gastric  catarrh  with  cramps  of  the 
stomach,"  may  finally  die  of  tabes.  But  gasti^algias  may  be  caused 
not  alone  by  sclerosis  of  the  posterior  columns,  but  also  by  other 
lesions  which  involve  the  vagus  nucleus.     Thus  Leyden  includes 

*  Von  Noorden.     Pathologic  der  gastrischen  Krisen.     Cliarite  Annalcn,  1890. 
f  [Cathelineau.     Arch.  gen.  de  nied,,  avril,  1894. — Ed.] 


492  -  DISEASES  OF   THE  STOMACH. 

them  among  the  symptoms  of  subacute  myehtis  ;  Oser  saw  them  in 
a  case  of  pressure  myelitis  following  vertebral  caries.* 

These  gastralgias  would  always  be  interesting  to  us,  even  if  they 
were  simply  symptoms  of  tabes  in  the  stage  of  complete  devel- 
opment ;  but  gastric  crises  are  not  infrequently  the  initial  symptom 
of  locomotor  ataxia.  This  lends  a  peculiar  importance  to  them ; 
hence  in  every  case  of  nervous  gastralgia  a  thorough  examination 
should  be  made  in  this  direction,  and  frequently  enough  we  may 
discover  other  symptoms  of  the  disease  which  had  not  been  noticed 
by  the  patient. 

3w  Gastralgias  from  Constitutional  Causes. — These  include  the 
cases  occurring  in  neurasthenia,  hysteria,  certain  psychoses,  and  pri- 
mary anaemia. 

It  is  important,  not  alone  for  the  semeiology  but  also  for  the 
prognosis,  that  neurasthenia  be  distinguished  from  hysteria,  and,  as 
this  will  not  be  accomplished  by  the  epigram  that  "  neurasthenia 
includes  rational  sensations,  hysteria  those  which  are  irrational,"  I 
shall  therefore  endeavor  to  distinguish  these  two  conditions  in  the 
following,  in  so  far  as  it  is  essential  for  the  gastric  manifestations. 

Neurasthenic  Gastralgias. — The  expression  asthenia  was  intro- 
duced by  Brown,  and  was  later  applied  by  Broussais  in  the  doctrine 
of  irritants  ;  it  denotes  a  condition  of  weakness  of  an  organ  which 
is  at  first  manifested  by  a  morbidly  increased  irritability,  and  later 
by  a  diminution  of  its  functional  activity.  Therefore,  the  term 
neurasthenia  indicates  an  enfeebled  condition  of  the  nervous  system 
and  the  consequences  thereof.  It  is  marked  by  a  continuous  and 
advancing  course,  and  seldom  occurs  without  causal  factors  of  an 
enfeebling  nature,  mental  overexertion,  strong  emotions,  sexual  ex- 
cesses, anaemic  conditions,  etc. 

Rosenthal  draws  a  sharp  distinction  between  the  irritative  and 
depressive  forms,  the  former  being  recognized  by  manifestations 
which  are  pre-eminently  those  of  irritation,  the  latter  by  symptoms 
of  exhaustion.  Both  are  related  to  each  other  by  numerous  tran- 
sitional forms,  and  are  characterized  as  follows  by  this  experi- 
enced neurologist :  "  The  patients  suffering  from  irritative  neuras- 

*  Oser,  loc.  cit.,  p.  43. 


GASTRALGIA.  493 

tlienia  complain  of  diffuse  or  circumscribed  headache,  which  is 
associated  (especially  in  an  attack)  with  local  cutaneous  hyperalgia 
and  acoustic  or  optic  hypersesthesia.  Marked  mental  excitability, 
uncalled-for  depression  of  spirits,  and  sensations  of  fear  and  in- 
ability to  speak  or  read  for  a  prolonged  period,  indicate  unusual 
central  irritability  and  exhaustion.  Equally  annoying  to  the  pa- 
tients are  the  periodical  pains  in  the  spine,  with  points  douloureux 
in  the  nape  of  the  neck,  more  frequently  between  the  scapulae,  less 
often  lower  down.  Electrical  and  thermal  stunulation  also  cause  a 
peculiar  sensitiveness  here,  especially  over  the  spinous  and  trans- 
verse processes.  This  secondary  condition  of  irritation  in  the  dis- 
tribution of  the  sensory  roots  may  be  demonstrated  more  accurately 
and  positively  by  means  of  electricity.  Most  frequently  I  found  a 
striking  sensitiveness  on  the  left  side  toward  cathodal  irritation  and 
the  f aradic  brush  which  extended  like  half  a  girdle  over  the  points 
douloureux  in  its  path,  and  over  which  it  was  most  pronounced. 
Yague  neuralgias  or  parasthesise  in  the  upper  and  lower  extremi- 
ties, becoming  easily  tired  and  exhausted  after  exercise  and  work, 
noticeable  increase  of  the  cutaneous  and  patellar  reflexes,  as  well  as 
disturbances  of  sleep  and  appetite,  constitute  many  of  the  patho- 
logical variations  of  irritative  neurasthenia.  When  located  in  the 
chest,  periodical  cardialgias  are  frequently  present.  We  may  also 
often  observe  that  increase  of  the  pain  in  the  back,  and  of  the  ten- 
derness over  the  cervical  and  dorsal  vertebrae,  together  with  fullness 
of  the  head,  are  the  forerunners  of  the  periodically  recurring  gas- 
tralgia.  ISTot  infrequently  there  are  also  localized  hyperassthetic 
areas  on  the  trunk,  and  puncta  dolorijiGa  may  be  more  prominent 
as  well  as  more  abundant.  More  or  less  rapidly  these  are  now  fol- 
lowed by  pain  in  the  stomach,  the  intensity  of  which  gradually  in- 
creases. 

"  The  pain  is  characterized  sometimes  as  '  drawing  together,' 
sometimes  as  boring,  and  radiates  from  the  lower  ribs  to  the  epigas- 
trium ;  it  is  accompanied  by  the  vaso-motor  symptoms,  and  those 
due  to  the  cerebral  anc?mia,  which  have  already  been  described. 

"  The  dejjressive  form  of  neurasthenia  presents  itseK  thus :  The 
patients  coinplain,  esjDecially  after  eating,  of  an  oppressive  sensation 
or  a  dragging  which  extends  from  the  stomach  into  the  abdomen, 


494  DISEASES   OP   THE   STOMACH. 

without,  however,  having  the  paroxysmal  character  of  the  painful 
gastralgias.  The  pain  in  the  back  is  also  not  so  intense,  nor  is  it  of 
so  neuralgic  a  character ;  on  the  other  hand,  the  motor  exhaustion, 
sexual  weakness,  seminal  emissions,  mental  depression,  and  atonic 
dyspepsia  are  especially  predominant.  The  diagnosis  of  a  localized 
spinal  meningitis,  which  is  not  infrequently  resorted  to,  may  be 
avoided  by  observing  that  in  the  latter  the  intense  and  usually 
widely  distributed  pain  in  the  back  is  ushered  in  by  fever,  tonic 
contractions  of  the  muscles  of  the  nape  of  the  neck  and  the  back 
prevent  any  movements,  contractures  and  partial  paralyses  may 
occur  in  the  extremities,  and  finally  pain  in  the  stomach  is  extremely 
rare  and  temporary." 

To  this  description  I  must  add  Burkart's  painful  points.'^  On 
pressing  deeply  down  to  the  retroperitonseum,  over  the  region  of 
the  superior  hypogastric,  aortic,  and  coeliac  plexuses,  the  patient 
experiences  exceedingly  sharp  and  unpleasant  pains,  which  radiated 
up  to  the  epigastrium.  Burkart  claims  to  have  found  these  points 
in  all  cases.  In  1884,  in  the  discussion  on  nervous  dyspepsia  at  the 
third  Congress  for  Internal  Medicine,f  I  stated  that  in  my  expe- 
rience this  was  not  always  the  case,  Richter  :j;  also  asserts  that,  as  a 
rule,  pressure  over  the  stomach  and  abdomen  is  not  painful.  Since 
then,  this  has  been  agreed  to  by  others.  At  that  time  I  said  that 
the  same  was  true  of  the  above-mentioned  painful  points  along  the 
spinal  column,  upon  which  so  much  stress  was  laid  by  Rosenthal, 
They  may  be  present  (according  to  Rosenthal,  in  Y5  per  cent  of  the 
cases),  or  they  may  be  absent ;  but,  even  if  they  are  present,  they 
have  no  important  bearing  on  the  conception  of  the  disease,  and  are 
by  no  means  one  of  its  essential  features.  On  the  contrary,  I  will 
say  that  my  further  experience  has  been  that  pain  along  the  spinal 
column,  both  on  pressure  and  with  the  faradic  bruch,  may  fre- 
quently be  absent  in  undoubted  cases  of  neurasthenia. 

Here  I  may  also  classify  the  condition  which  Buch*  has  de- 

*  E,.  Burkart.     Zur  Pathologie  der  Neurasthenia  gastriea.     Bonn,  1882, 
f  Verhandlungen  des  Congresses  fiir  innere  Mediein,  1884,  S.  232. 

X  Riehter.  Ueber  nervose  Dyspepsie  und  nervose  Enteropathie.  Berliner  klin. 
Wochenschr.,  1883,  No.  13. 

*  Buch.  Wirbelweh,  eine  neue  Form  der  Gastralgia.  St.  Petersburger  med. 
Wochenschr.,  1889,  No.  23. 


GASTRALGIA.  495 

scribed  as  a  separate  form  of  nervous  disorder  under  the  name  of 
"  Wi7'helweh  "  [vertebral  pain] — i.  e.,  the  pains  which  are  produced 
by  pressure  made  in  the  epigastrium,  or  at  the  level  of  the  umbili- 
cus, upon  the  anterior  surface  of  the  lumbar  vertebrae.  They  are 
usually  accompanied  by  a  subjective  feeling  of  more  forcible  pulsa- 
tion of  the  abdominal  aorta ;  they  do  not,  however,  occur  if  pressure 
is  made  on  both  sides  alongside  of  the  vertebral  column.  At  times, 
though  not  always,  the  spinous  processes  are  also  sensitive.  Among 
the  accompanying  symptoms  are  nausea,  eructation,  ravenous  appe- 
tite, with  nausea  and  languor.  The  stools  are  variable ;  constipation 
is  the  rule,  although  diarrhoea  may  occur. 

Buch  correctly  assumes  this  condition  to  be  a  neurosis  of  the 
sympathetic  plexus  which  proceeds  from  the  plexus  aorticus  abdomi- 
nalis  and  the  plexus  hypogastricus,  and  supplies  the  bodies  of  the 
vertebrae  and  the  intervertebral  disks  with  nerve-filaments.  But  this 
condition  was  recognized  long  ago,*  and  is  also  mentioned  by  me, 
on  page  493,  among  the  symptoms  of  gastralgia.  It  remains  ques- 
tionable whether  these  cases  ought  to  be  grouped  in  a  separate  class. 
Buch  claims  to  have  had  good  effects  from  injections  of  antipyrin 
m  loco  affecto ;  but  this  is  rendered  doubtful,  because  at  the  same 
time  he  also  used  all  the  ordinary  means  of  physiatric  treatment,  in- 
cluding cold  rubbings,  douches,  baths,  gymnastics,  diet,  etc. 

The  following  case  may  serve  as  a  typical  example  of  this 
kind: 

In  August,  1885,  a  merchant,  forty-five  years  old,  was  broug-ht  to  me 
by  his  family  physician.  He  complained  of  great  fatigue,  especially  a 
feeling  of  heaviness  in  his  legs,  disinclination  for  work,  and  dullness  and 
confusion  of  the  head,  especially  after  eating.  His  appetite  was  capri- 
cious, and  he  never  dared  to  eat  the  same  thing  many  times  in  succession. 
For  the  past  six  weeks  he  had  suffered  severely  from  painful  attacks  of 
gastralgia,  which  at  first  were  far  apart,  but  later  occurred  daily,  and 
sometimes  even  several  times  a  day.  Although  they  did  not  occur  imme- 
diately after  eating,  yet  he  thought  that  they  were  caused  by  eating,  and 
consequently  had  restricted  his  diet ;  as  a  result  he  lost  over  ten  pounds 
in  weight.  A  course  of  treatment  for  three  weeks  at  Carlsbad  had  not 
alone  not  benefited  him,  but  had  even  made  him  much  worse.  The 
bowels  were  constipated.  The  patient  a  very  active  person,  well  nour- 
ished but  pale,  was  the  proprietor  of  a  very  large  factory  employing  over 

*  Hornbaum.  Ueber  die  Pulsation  in  der  Oberbauchgegend  als  begleitendes 
Symptom  der  Indigestion.     Hildburgshausen,  1836. 


496  DISEASES  OF  THE  STOMACH. 

one  hundred  people,  a  number  of  whom  were  engaged  outside  of  Berlin  ; 
he  had  to  oversee  many  of  their  trips,  and  consequently  was  frequently 
agora vated  and  worried.  The  illness  of  his  partner  for  a  time  threw  the 
entire  responsibility  upon  him.  A  year  previously  he  had  had  a  similar 
attack. 

The  physical  examination  revealed  no  abnormalities;  all  signs  of 
spinal  and  intercostal  neuralgise,  as  well  as  painful  points,  were  absent. 
On  the  other  hand,  the  tendon  reflexes  were  markedly  increased.  The 
chemical  processes  of  the  stomach  (after  the  test  breakfast)  were  found 
normal. 

At  the  first  glance  it  was  apparent  that  this  was  a  tolerably  clear  case 
of  nervous  gastralgia,  in  spite  of  the  absence  of  the  painful  points,  the 
symptom  upon  which  so  much  stress  had  been  laid.  The  treatment  con- 
firmed the  diagnosis.  At  first  bromide  of  potassium  was  used  ;  later,  a  so- 
journ for  several  weeks  at  one  of  the  resorts  on  the  Baltic  Sea  caused  the 
cessation  of  the  attacks,  and  the  patient  then  gained  rapidly  in  weight. 
The  rest  was  accomplished  by  a  proper  diet  and  hygienic  measures  (daily 
sponging  and  riding).  Up  to  the  present  time  the  attacks  have  not  re- 
curred. 

I  must  not  omit  to  mention  how  difficult  it  is  in  such  cases  to 

exclude  the  presence  of  biliary  colic.     Even  in  the  above  case  this 

point  is  not  definitely  settled.    Undoubtedly  there  are  cases  of  biliary 

colic  without  icterus,  distention  of  the  gall  bladder,  and  fever,  and 

in  which  the  diagnosis  between  an  affection  of  the  liver  and  the 

stomach  can  not  be  made.     Among  the  cases  of  pure  gastralgia 

under  my  care  quite  a  number  are  marked  with  an  interrogation 

point.     The  following  may  be  quoted  as  an  example : 

A  well-nourished  woman,  thirty  years  old,  the  mother  of  seven  chil- 
dren, had  formerly  never  had  pain  in  the  stomach  ;  five  years  previously, 
after  the  birth  of  the  fifth  child,  had  "  biliary  colic  "  ;  had  been  to  Carls- 
bad twice  and  obtained  relief  ;  for  the  past  year  has  had  painful  cramps 
in  the  stomach,  at  first  infrequently,  lately  every  fortnight.  Physical  ex- 
amination was  negative.  The  uterus  was  pronounced  normal  by  a  gyn- 
ecologist. Never  had  belching  or  vomiting ;  between  the  attacks  the 
appetite  was  good.  The  bowels  are  constipated  after  the  attacks,  other- 
wise regular.  Although  considerable  relief  was  afforded  by  regulating 
the  diet,  drinking  the  water  of  the  Marienbader  Kreuzbrunnen,  and 
taking  soda  to  which  small  doses  of  morphine  had  been  added ;  yet,  dur- 
ing the  two  months  in  which  the  patient  was  under  my  observation,  she 
still  had  occasional  attacks,  although  less  severe  in  character.  I  consid- 
ered the  diagnosis  doubtful,  in  spite  of  the  fact  that  the  patient  no  longer 
referred  the  pain  to  the  right  hypochondrium  as  formerly,  but  to  the 
middle  line,  and  even  to  the  left  of  it ;  the  reason  was,  that  we  know  that 
attacks  of  biliary  colic  may  be  followed  by  inflammation  of  the  gall  blad- 
der, with  the  subsequent  formation  of  adhesions  to  the  adjacent  viscera, 
the  stretching  of  which  may  produce  colicky  pains. 


GASTRALGIA  497 

Hysterical  Gastralgias. — It  is  only  the  peculiar  nature  of  hys- 
teria which  will  enable  us  to  recognize  as  hysterical  the  attacks  of 
gastralgia  which  may  occur  during  its  course. 

In  the  following  remarks  I  do  not  by  any  means  propose  to  give 
a  thorough  description  of  the  protean  picture  of  hysteria ;  I  simply 
wish  to  give  a  few  suggestions,  upon  the  completeness  of  which  I 
lay  very  little  stress,  because  the  characteristic  features  of  this  dis- 
ease are  not  difficult  to  recognize. 

In  this  affection,  unlike  neurasthenia,  the  psychical  factors,  per- 
verse thoughts  and  sensations,  occupy  a  pre-eminent  place.  The  tend- 
ency toward  extraordinary  behavior,  the  conscious  or  unconscious 
longing  to  be  conspicuous  by  any  means  whatsoever,  the  turning 
away  from  every  serious  occupation,  the  degradation  into  the  peculiar, 
fantastic  existence  about  which  the  patient's  entire  being  revolves, 
the  capricious,  willful,  and  impulsive  actions  are  not  those  of  ordi- 
nary life,  and  these  are  all  aberrations  from  normal  thought  and  sen- 
sation, denoting  profound  changes  in  the  psychical  processes.  As- 
sociated with  them  are  the  manifold,  objectively  demonstrable  nerv- 
ous disturbances,  convulsions,  paralyses,  pupillary  inequalities,  hemi- 
anaesthesise,  and  changes  in  electrical  sensibility.  The  manifestations 
of  transference  give  additional  symptoms.  In  the  affections  with 
gastric  disturbances  I  have  been  particularly  struck  by  the  absence 
or  lessening  of  the  electro-cutaneous  sensitiveness  of  the  abdominal 
parietes;  this  sign  was  not  absent  even  where  other  hysterical 
symptoms  were  scarcely  manifested.  A  marked  example  of  this  is 
afforded  in  the  following  history  which  I  shall  relate  in  the  exact 
words  of  the  physician  who  sent  the  case  to  me : 

The  patient  is  a  lady,  fifty-two  years  of  age,  the  history  of  whose  suf- 
ferings is  a  very  long  one.  Soon  after  marriage  she  began  to  be  troubled 
with  haemorrhoids  ;  constipation  was  always  present.  For  years  she  had 
suffered  from  chronic  metritis  and  endometritis ;  the  menses  were  very 
profuse,  lasted  eight  days,  and  were  accompanied  by  many  disturbances. 
Temporary  relief  was  obtained  by  douches,  sitz  baths,  local  applications 
to  the  cervical  canal,  and  evacuants.  To  obtain  better  results  she  was  sent 
to  Elster  ;  here  the  severe  haemorrhages  lessened,  yet  now  there  were  very 
frequent  disturbances  of  digestion  combined  with  pains  in  the  lumbar, 
inguinal,  and  umbilical  regions.  In  this  year  she  was  sent  to  Kissingen, 
on  account  of  the  incessant  complaints  produced  by  variously  located 
symptoms  due  to  stagnation  of  the  portal  circulation.  Here,  for  the  first 
time,  there  were  also  pains  and  stitches   in   the  breast,  which  usually 


498  DISEASES  OP  THE  STOMACH. 

appeared  after  midnight,  and  in  fact  began  only  at  night,  very  suddenly, 
and  with  great  severity  ;  after  lasting  for  hours  they  ceased,  with  marked 
eructation.  Sometimes  these  symptoms  appeared  on  several  consecutive 
nights ;  at  other  times  the  patient  might  be  free  for  a  number  of  nights. 

The  patient  appeared  to  be  easily  excitable,  and,  although  emaciated, 
was  very  well  preserved  for  her  years  ;  on  the  back  of  the  left  hand  and 
forearm  there  was  an  absolutely  anaesthetic  zone  ;  patellar  reflexes  absent ; 
the  abdominal  j)arietes  were  very  sensitive,  even  to  delicate  palpation ;  on 
the  other  hand,  faradic  brushing  was  scarcely  felt  here,  although  it  was 
painful  on  the  face,  arms,  and  legs.  Undoubtedly  this  was  a  hysterical 
condition  accompanying  a  reflex  dyspepsia,  proceeding  from  the  uterus, 
the  symptoms  of  the  latter  being  especially  prominent. 

The  alternation  with  neuralgias  or  neuroses  in  other  organs  is 
characteristic  of  hysterical  gastralgias.  Oser  reports  a  typical  case 
of  this  kind  in  which  hysterical  aphonia  alternated  with  attacks  of 
gastralgia;  this  case  suggests  very  strongly  that  the  nucleus  of 
the  vagus  was  involved.  I  have  had  under  my  observation  for  a 
long  time  a  case  in  which,  together  with  persistent  constipation — 
the  bowels  are  never  spontaneously  evacuated — peculiar  sensations 
are  experienced  in  the  abdomen,  so  that  the  patient  thinks  that  a 
frog  is  in  her  stomach ;  at  other  times  she  imagines  she  has  swal- 
lowed a  needle,  or  that  she  has  a  tumor ;  at  times  she  also  has  at- 
tacks of  hysterical  hoarseness  and  aphonia.  Occasionally  she  also 
has  attacks  of  true  gastralgia. 

Some  time  ago  I  had  the  opportunity  of  seeing  a  case  of  hyster- 
ical gastralgia,  which  was  so  characteristic  that  it  deserves  mention 
here,  especially  as  the  treatment  renders  it  remarkable : 

On  April  1, 1888,  I  was  summoned  to  a  distant  suburb  for  a  consulta- 
tion. When  I  arrived  there  the  family  physician  was  not  present,  because, 
as  I  was  told,  he  said  that  "  nothing  could  be  done  for  the  case."  I  found 
a  small,  delicate  woman  of  thirty  years,  very  much  retarded  in  her  growth ; 
she  was  living  with  her  mother  in  great  poverty,  and  had  been  in  bed  for 
eight  months  because  she  claimed  to  be  too  weak  to  walk.  What  little 
nourishment  she  took  was  liquid  ;  nevertheless,  she  was  tortured  with 
such  severe  paroxysms  of  gastralgia  that,  as  her  mother  stated,  she  scraped 
the  chalk  off  the  walls  and  disturbed  the  house  by  her  screaming.  In 
her  childhood  she  was  said  to  have  had  chorea.  On  physical  examina- 
tion there  was  pain  on  pressure  over  the  ovaries  and  in  the  infrasternal 
depression ;  no  anaesthetic  areas,  patellar  reflexes  present,  tongue  clean, 
no  fetor  ;  at  no  times  vomiting,  stools  very  constipated,  and  like  scybalae. 
The  diagnosis  of  hysteria  was  beyond  doubt.  To  show  the  patient  that 
she  could  walk,  I  took  her  out  of  the  bed  and,  supporting  her  under  the 
arms,  dragged  her  about  the  room.    As  I  had  thus  convinced  myself 


GASTRALGIA.  499 

that  there  were  no  organic  paralyses,  I  ordered  her  to  visit  me  the  next 
morning-.  During  my  otfice  hours  I  was  disturbed  by  a  loud  noise  ;  it  was 
the  patient,  who  had  come  to  my  house  in  a  cab  after  a  ride  of  about  forty- 
five  minutes,  had  been  carried  upstairs  by  the  coachman,  and  could  go 
about  the  room  when  supported  by  two  persons.  I  washed  out  the  stom.- 
ach  to  examine  its  chemical  functions,  to  reduce  the  hypersensitiveness, 
and  also  to  produce  a  moral  effect ;  while  introducing  the  tube  she  became 
very  cyanotic.  No  free  hydrochloric  acid  was  found  in  the  wash-water. 
I  prescribed  hydrochloric  acid,  tincture  of  belladonna,  and  cocaine.  Six 
days  later  she  came  again ;  but  this  time  she  was  alone,  had  walked  up 
the  stairs  very  slowly  and  with  great  exertion,  yet  without  any  help  ;  but 
after  that  she  had  a  typical  attack  of  hysterical  barking  cough.  The 
stomach  was  again  washed  out ;  no  free  acid,  and  a  little  peptone  was 
found.  Three  days  later  she  came  upstairs  alone.  The  cough  had  dis- 
appeared ;  had  occasional  but  only  slight  pains.  Began  to  have  appetite. 
The  stomach  was  washed  out  twice  more  at  several  days'  intervals.  On 
May  31st  I  recorded  that  speech  was  good  ;  walked  without  aid,  simply  by 
holding  her  hand  lightly ;  complained  still  of  nausea,  pain  in  abdomen 
after  eating  and  walking,  and  heaviness  in  the  legs.  The  stomach  was 
found  empty  two  hours  and  a  half  after  the  test  breakfast.  Arsenic  and 
iron  were  ordered,  and  she  was  sent  to  the  country.  In  the  fall  the 
mother  reported  that  with  the  exception  of  trivial  ailments  she  had  kept 
well. 

I  do  not  consider  tins  case  at  all  extraordinary.  Similar  cases 
occur  every  day,  although  possibly  the  cure  is  not  so  remarkable. 

It  is  superfluous  to  enter  into  further  details  on  this  subject,  as 
such  cases  occur  frequently  in  practice.  The  gastralgias  constitute 
only  one  link  in  the  chain  of  the  manifold  group  of  symptoms ;  the 
only  point  is,  not  to  be  deceived  about  the  true  nature  of  the  at- 
tacks, and  to  recognize  the  hysterical  basis.  This  is  usually  easy  in 
most  cases,  but  it  may  "be  very  difficult,  especially  when  the  hysteria 
is  manifested  by  only  one  symptom — for  example,  gastralgic  attacks 
in  old  women,  or  even  in  men.  To  exhaust  all  these  possible  forms 
would  take  me  far  beyond  my  province. 

Finally,  gastralgias  may  also  occur  in  psychoses,  and,  what  is  es- 
pecially important,  may  be  among  the  prodromal  symptoms. 

For  a  year  and  a  half  I  treated  a  young  engineer  for  gastralgia  associ- 
ated with  neurasthenia.  He  finally  became  melancholic  and  committed 
suicide.  Psychoses  had  already  occurred  in  the  family,  and  one  brother 
had  died  in  an  insane  asylum. 

In  these  cases  the  chemical  functions  of  the  stomach  were 
normal,  so  far  as  could  be  determined.  On  pages  216  et  seq., 
while  considering  chronic  gastritis,  I  have   already   discussed  the 


500  DISEASES  OP   THE  STOMACH. 

nervous  symptoms  and  psychoses  wliich  may  accompany  or  follow 
well-marked  disturbances  of  the  functions  of  the  stomach.  The 
views  there  expressed  have  been  corroborated  by  Alt,*  who  has 
described  a  number  of  excellent  examples  of  agoraphobia,  melan- 
cholia, and  conditions  of  fear  which  sometimes  even  became  halluci- 
nations, in  which  improvement  or  cure  followed  suitable  treatment 
directed  to  the  gastric  disturbances  present.  Most  of  the  cases  were 
gastrectases  with  disturbances  of  secretion.  Alt's  observations  led 
him  to  fully  accept  my  views  of  agoraphobia. 

As  excessive  or  perverted  sexual  intercourse  may  be  regarded 
among  the  psychoses,  we  may  also  include  here  the  cases  in  which 
gastralgias  occur  after  frequent  pollutions.  I  have  repeatedly  seen 
examples  of  this  in  young  men. 

*  K.  Alt.  Ueber  das  Entstehen  von  Neurosen  und  Psychosen  auf  dem  Boden 
von  chronischen  Magenkrankheiten.  Arch,  fiir  Psych,  und  Nervenkrankheiteu, 
Bd.  xxiv,  p.  403. 


CHAPTEK  XI. 

THE   NEUROSES    OF   THE    STOMACH    (CONTINUED). 

I  coNSiDEK  hyperchlorhydria  and  hypersecretion  of  the  gastric 
juice  to  be  sensory  neuroses  of  the  secretory  function.  Eeichmann 
deserves  the  credit  of  having  been  the  first  to  thoroughly  study  this 
subject  with  our  modern  methods  in  1882  and  1883  ;  yet  it  is  an  error 
to  suppose  that  these  conditions  were  unknown  formerly.  Even 
Riegel  makes  this  mistake  in  his  last  publication,*  in  spite  of  what  I 
have  already  said  on  this  point.  On  the  contrary,  they  were  de- 
scribed almost  fifty  years  ago  by  Pemberton,  Copland,  Todd,  Budd, 
Trousseau,  and  among  the  Germans  by  Hiibner ;  f  but  later,  as 
these  descriptions  were  based  upon  speculation  rather  than  upon 
direct  observation,  they  passed  into  oblivion.  Recently  this  subject 
has  been  especially  investigated  by  the  above  [Reichmann],  Jawor- 
ski.  Yon  den  Yelden,  Riegel,  Saly,  Von  ISToorden,  and  Honig- 
mann. 

Hyperchlorhydria  is  an  increase  above  the  normal  of  the  amount 
of  hydrochloric  acid  secreted  ;  it  is  due  to  the  stimulation  of  the 

*  Riegel.     Deutsch.  med.  Wochenschr.,  1892,  No.  31. 

f  As  early  as  1820,  Pemberton  (Treatise  on  the  Various  Diseases  of  the  Abdomi- 
nal Viscera)  speaks  of  "  a  morbidly  increased  secretion  from  the  stomach,  analo- 
gous to  a  diabetic  secretion  of  urine  by  the  kidneys" ;  also  Copland  :  "  Or  in  other 
words,  that  pyrosis  is  produced  by  the  continuance  of  the  secretion  of  the  gastric 
juices  after  the  food  taken  into  the  stomach  has  passed  into  the  duodenum."  Budd 
also  says  that  pains,  etc.,  may  arise  "from  the  presence  of  free  acid  in  the  empty 
stomach."  Trousseau  (Des  Dyspepsies,  L'Union  med.,  1857,  p.  306) :  "  Le  neuralgie 
de  I'estomac  augmente  les  secretions  acides  a  ce  point  qu'elles  se  ferront  non  plus 
comme  d'habitude  au  moment  de  la  digestion  mais  encore  en  dehors  de  ces  mo- 
ments." In  Hiibner  (Die  gastrischen  Krankheiten  monographisch  dargestellt,  Leip- 
zig, 1844,  S.  209)  we  find  the  following  :  "  If  the  morbidly  altered  secretion  of  the 
gastric  juice  ...  is  the  cause  of  the  acid,  then  the  patient  suffers  uninterruptedly 
from  it ;  he  may  eat  what  he  will,  the  symptoms  become  more  marked,  and,  as  the 
cause  persists,  it  becomes  more  obstinate  than  in  the  formation  of  acid  by  fer- 
mentation," 

501 


502  DISEASES  OF  THE  STOMACH. 

ingesta,  tlie  acidity  of  which  is  heightened  after  being  incorporated 
therewith.  JN^aturally,  it  is  difficult  to  determine  where  the  normal 
acidity  ceases  and  the  abnormal  hyperacidity  begins,  as  a  sharp  line 
like  the  zero  point  in  a  thermometer  can  not  be  drawn ;  on  the  con- 
trary, there  must  always  be  an  intermediate  stage  in  which  the 
quantity  of  the  secretion  depends  on  individual  circumstances;  here 
we  remain  in  doubt  whether  this  should  be  called  hyperacidity  or 
not.  However,  from  the  average  of  a  very  large  number  of  exami- 
nations after  the  test  breakfast  I  consider  that  hyperacidity  begins 
when  the  amount  of  acid  is  between  60  and  70  per  cent. 

1  have  already  spoken  of  the  relation  of  hyperacidity  to  gastric 
ulcer ;  but  it  is  beyond  doubt  that  this  condition  may  exist  as  a  pri- 
mary neurosis  independently  of  any  organic  lesions.  Yon  JN^oorden 
has  observed  it  in  melancholia,*  Jolly  claims  that  there  is  an  in- 
creased secretion  of  gastric  juice  in  hysteria,  and  Jaworskif  has 
frequently  found  it  among  the  Jews  of  Galicia,  who  are  especially 
predisposed  to  nervous  disturbances.  It  may  also  occur  as  a  reflex 
symptom  of  gall  stones  and  renal  calculi ;  and  also  where  all  of 
these  factors  are  absent  the  neurotic  basis  of  the  disorder  may  be 
recognized  by  the  want  of  success  in  treatment  directed  toward  the 
cure  of  a  supposed  gastric  ulcer. 

In  the  summer  of  1887  I  treated  a  girl  of  nineteen  years  for  nearly 
three  months  for  a  supposed  gastric  ulcer,  because  she  had  periodical  gas- 
tralgia,  and  a  hyperacidity  of  88  per  cent.  The  absolute  failure  of  the 
treatment,  and  the  constant  recurrence  of  the  attacks,  in  spite  of  the  im- 
provement in  the  general  condition  and  the  increase  in  weight,  indicated 
a  purely  neurotic  basis  of  the  disorder,  although  other  symptoms  of  neur- 
asthenia and  hysteria  were  lacking. 

Hypersecretion,  or  better,  jparasecretion^  gastrosuccorrhcea  (the 
Magensaftfluss  of  Reichmann),  may  occur  in  two  forms,  the  pe- 
riodic and  the  continuous.  The  acidity  is  not  increased,  as  a  rule, 
in  the  former,  but  it  is  in  the  latter.  In  th.e  periodic  form  it  usually 
occurs  after  eating,  rarely  while  fasting,  yet  it  does  not  seem  to 

*  Sitzungsbericht  der  medicin.  Gesellschaft  zu  Giessen.  Abstract  in  Berlin,  klin. 
Wochenschr.,  1887,  No.  18. 

f  W.  Jaworski.  Zusammenhang  zwischen  subjectiven  Magensymptoraen  und 
objectiven  Befunden  bei  Magenfunctionsstorungen.  Wiener  med.  Wochenschr., 
1886.  Nos.  49-52. 


HYPERCHLORHYDRIA.  503 

have  a  direct  connection  with  the  introduction  of  food.     "Wilkens  * 
reports  a  typical  case  of  this  kind. 

A  musician,  thirty-six  years  old,  who  led  an  emotional  life,  for  the 
preceding  three  years  and  a  half  had  attacks  of  vomiting  and  pain  in  the 
stomach  ;  during  the  paroxysms  he  could  neither  eat  nor  drink,  and  had 
to  go  to  hed.  Similar  attacks,  which  lasted  twenty-seven  to  thirty-five 
hours,  recurred  at  intervals  of  ten  to  twelve  days.  He  lost  in  weight 
from  2  to  3^  kilogrammes  [4^  to  7f  pounds].  Intense  hunger  between  the 
attacks.  The  gastric  juice  vomited  was  about  two  pounds  and  a  half,  and 
every  time  had  0"12  per  cent  HCl.  Diagnosis,  affection  of  the  secretory 
nerves. 

All  writers  agree  that  the  condition  is  a  functional  disturbance 
of  the  nerves  of  the  stomach,  which  may  occur  alone  or  as  part 
of  other  neuroses.  I  can  therefore  not  understand  why  Riegel  f 
denies  the  nervous  nature  of  this  condition.  That  it  occurs  in  all 
classes,  as  has  been  correctly  claimed  by  Eiegel,  is  no  argument 
against  this,  for  it  is  well  known  that  neuroses  occur  in  all  classes 
of  society. 

In  continuous  hypersecretion  [continuirliche  Magensaftfiuss) 
there  is  a  continuous  secretion  of  gastric  juice  which  is  usually 
hyperacid,:]:  so  that  even  while  fasting  the  stomach  may  contain 
smaller  or  larger  quantities,  varying  between  100  and  1,000  c.  c, 
[f  5  iijss.  to  Oij],  or  more,  of  a  fluid  very  much  resembling  ordi- 
nary gastric  juice,  but  without  any  remnants  of  food,  and  frequently 
tinged  grass-green  or  bluish-green  by  the  admixture  of  bile.*  The 
degree  of  acidity  is  high,  but  the  amount  of  free  hydrochloric  acid 
which  can  affect  the  color  reagents  is  very  variable,  as  has  been 
shown  by  Jaworski ;  \  since  in  cases  with  the  same  degree  of  acid- 
ity, in  some  there  was  much  free  acid  and  a  feeble  biuret  reaction ; 
in  others,  like  free  acid,  in  spite  of  the  absence  of  organic  acids  and 


*  S.  A.  Wilkens.  A  Case  of  Hypersecretion  in  Intermittent  Attacks.  Lancet, 
August  27,  1887. 

f  Riegel.  Ueber  ehronisch-continuirliche  Magensaftsecretion.  Deutsch.  med. 
Wochenschr.,  1892,  No.  21. 

X  Jaworski,  loc.  cit. — in  121  cases  of  hypersecretion,  hyperacidity  was  found  at 
the  same  time  in  115  of  them. 

*  Jaworski,  loc.  cit. — 77  times  in  222  cases. 

II  Jaworski.     Ueber  die  Verschiedenheit  in  der  BeschafEenheit  des  niichternen 
INIagensaftes  bei  Magensaftfiuss  (Gastrorrhoea  acida).      Verhandlungen  des  Con- 
gresses f.  innere  Med.     Wiesbaden,  1888,  S.  280. 
33 


504  DISEASES  OP  THE  STOMACH. 

a  marked  biuret  action ;  finally,  in  rare  cases  having  a  certain  degree 
of  acidity  no  reactions  can  be  obtained,  althongb  one  would  expect 
a  positive  result  with  all  the  color  tests.  Jaworski  attributes  this  to 
the  larger  or  smaller  admixture  of  desquamated  tissue  elements  of 
the  mucous  membrane  or  emigrated  white  blood  cells,  or  even  blood 
serum,  which  by  forming  peptone  or  acid  combinations  may  com- 
bine with  part  or  all  of  the  free  hydrochloric  acid.  Swallowed 
saliva  or  bronchial  secretion  may  take  an  active  part  in  this ;  they 
are  usually  found  in  stomach  contents  in  the  form  of  greenish 
masses. 

It  is  found  that  the  digestion  of  starches  is  delayed,  but  is  very 
prompt  in  albuminoids,  so  that  after  a  meal  consisting  of  meat  and 
amylaceous  substances  one  may  find  abundant  remnants  of  undi- 
gested starches,  but  no  trace  of  meat  (Riegel).  While  fasting,  the 
fluid  in  the  stomach  no  longer  contains  the  usual  varieties  of  epi- 
thelium, but  instead  many  nuclei  with  sharp  contours,  which  Trink- 
ler  *  (who  first  called  attention  to  them  in  animals),  Jaworski,  and 
myself  consider  to  be  remains  of  undigested  cells.  According  to 
Jaworski,  this  condition  of  chronic  hypersecretion  must  be  almost 
the  rule,  since  among  159  cases  he  found  115  with  hyperacid  and 
continuous  secretion.  Riegel  does  not  go  to  such  extremes,  yet  hs 
claims  that  it  occurs  in  about  half  of  all  the  cases  of  stomach  dis- 
orders. Other  writers,  especially  among  the  French,  for  example^ 
Matthieu,  agree  with  the  latter.  My  own  experience  would  lead 
me  to  make  the  proportion  even  less,  notwithstanding  the  fact  that 
in  the  last  few  years  I  have  examined  in  reference  to  this  point 
every  patient  whose  symptoms  lead  me  to  suspect  this  condition. 
We  must  leave  it  a  mooted  question  whether,  as  claimed  by  Yon 
den  Yelden,  hypersecretion  is  only  a  lengthened  reaction  toward  the 
stimulation  of  the  food,  or  whether  it  is  continuous,  as  asserted  by 
Keichmann,  Riegel,  myself,  and  others.  Under  certain  conditions, 
as  observed  by  Talma,t  the  stomachs  of  neurasthenics  may  react  ab- 
normally toward  acids. 


*  Trinkler.  Ueber  den  Bau  der  Magenschleimhaut.  M.  Schultze's  Archiv,  Bd. 
sxiv,  S.  195. 

t  S.  Talma.  Zur  Behandlung  von  Magenkrankheiten.  Zeitschrift  fiir  klin. 
Med.,  Bd.  viii,  S.  407. 


HYPERSECRETION  OP   GASTRIC  JUICE.  505 

Tlie  irritation  of  the  mucous  membrane  by  the  acid  fluid  causes 
hypersestliesia,  the  results  of  whieli  are  tenderness  or  pain  in  the 
epigastrium,  acid  eructation,  heartburn,  vomiting  of  sour  masses, 
gastralgias,  and  similar  digestive  disturbances  which  constitute  the 
symptoms  of  a  chronic  inflammatory  condition,  which  occur  not 
alone  during  the  day,  but  also  at  night  and  morning  when  the 
stomach  is  empty. 

The  absence  of  the  signs  of  a  catarrh  is  characteristic— i,  e., 
coated  tongue,  foul  breath,  and  loss  of  appetite ;  on  the  contrary, 
the  tongue  is  usually  clean,  and  the  appetite  is  increased  rather 
than  diminished.  Excessive  thirst  was  common  in  Jaworski's  cases, 
and  (what  is  by  no  means  wonderful)  was  said  to  have  been  relieved 
by  drinking  water  and  diluting  the  contents  of  the  stomach. 
Among  the  results  of  this  condition  we  must  consider  atony  of 
the  muscular  coat  of  the  stomach,  and  the  gastrectasis  due  to  it ; 
where  the  condition  has  lasted  a  long  time,  this  is  so  common  that 
twenty-nine  more  or  less  well-marked  dilatations  of  the  stomach 
were  found  in  thirty  cases  at  Prof.  Riegel's  clinic*  But  by  this 
time  the  neurosis  has  been  converted  into  an  organic  lesion,  and 
such  conditions  must,  therefore,  be  considered  among  the  cases  of 
gastrectasis,  and  not  among  the  gastric  neuroses.  [The  urine  is  al- 
kaline, contains  few  chlorides ;  but  phosphates  are  often  in  excess. 
The  bowels  are  usually  obstinately  constipated.] 

The  exact  diagnosis  of  this  condition  can  only  be  made  by  exam- 
ining the  stomach  contents,  and  so  far  as  concerns  chronic  hyper- 
secretion this  examination  must  be  made  while  fasting.  [Reich- 
mann  and  Riegel  recommend  that  the  stomach  be  washed  out  in  the 
evening,  after  which  nothing  is  to  be  eaten.  The  tube  is  then 
passed  early  the  next  morning,  while  fasting.]  A  clew  to  this  state 
is  afforded  by  the  fact  that  the  symptoms  are  temporarily  amelio- 
rated by  eating  proteids  ;  this  differentiates  it  from  the  disturb- 
ances caused  by  the  pyrosis  and  gastralgia  due  to  acid  feraientation. 
The  alkalies  give  temporary  relief  in  both  conditions  of  nervous 
hyperacidity  and  acid  fermentation  ;  yet  the  difference  is  this,  that 
for  the  former  we  have  no  other  direct  remedy  excepting  this  purely 

*  Honigmann,  loc.  cit. 


506  DISEASES  OF  THE  STOMACH. 

symptomatic  one ;  but  fermentation  may  be  controlled  and  pre- 
vented by  specific  measures. 

[Mucli  has  been  written  during  the  past  few  years  on  the 
subject  of  Reiclimann's  disease,  as  gastrosuccorrhcea  is  sometimes 
called.  In  spite  of  the  long  and  bitter  controversy  in  which 
Schreiber  and  Riegel*  have  been  engaged,  much  uncertainty 
still  prevails  as  to  how  much  is  to  be  included  under  this  term. 
I^either  is  it  yet  certain  whether  it  is  a  disease  sui  generis,  or 
simply  a  symptom  of  various  gastric  disorders,  or  whether  the 
gastrosuccorrhoea,  atony,  or  gastrectasis  is  the  primary  factor  of 
these  three  conditions  which  are  so  frequently  associated  to- 
gether. This  may  readily  be  appreciated  by  the  fact  that  Reich- 
mann  states  that  in  years  he  has  seen  only  6  cases,  while  Boas 
states  that  in  his  large  experience  he  has  only  encountered  10 
genuine  cases  of  the  chronic  f  orm.f  On  the  other  hand,  Bouveret  X 
maintains  that  he  has  seen  many  cases  of  it,  and  devotes  over  sixty 
pages  to  its  consideration.  Riegel,  Jaworski,  and  others  also  con- 
sider it  a  frequent  disease. 

Much  of  this  uncertainty  is  due  to  the  fact  that  for  a  long  time 
we  did  not  really  know  what  the  contents  of  the  stomach  were  while 
fasting.  It  is  now  acknowledged  that  acid  gastric  juice  may  be 
frequently  found  at  this  time  (see  page  20).  Another  reason 
which  may  be  given  is  that,  as  above  stated,  many  conditions  in 
which  hypersecretion  occurs  as  a  complication,  as  cases  of  dilatation, 
atony  of  the  stomach,  gastric  ulcer,  gastric  neurasthenia,  etc.,  with 
hyperchlorhydria,  are  regarded  as  examples  of  Reichniann's  disease. 

Pathologically,  some  observers,  as  Hayem,*  Korczynski,  and 
Jaworski  || ,  have  found  special  changes  in  the  gastric  mucous  mem- 
brane to  which  the  term  gastrite  hyperpeptigue  has  been  applied ; 
the  peptic  cells  undergo  degeneration,  but  the  parietal  cells  are  un- 
changed. They  would  also  connect  this  disease  with  the  so-called 
acid  catarrhal  gastritis. 

*  [See  files  of  Deutsch.  med.  Wochenschr.,  1893.— Ed.] 
f  [Quoted  from  Boas,  o'p.  cit.,  Bd.  ii,  p.  130. — Ed.] 

X  [Bouveret.    Traite  des  maladies  de  restomac.     Paris,  1893,  pp.  161-221. — Ed.] 

*  [Hayem.     AUgemeine  Wiener  med.  Zeit.,  1894,  No.  2,  etc. — Ed.] 

II  [Korczynski  und  Jaworski.    Deutsch.  Arch,  flir  klin.  Med.,  Bd.  xlvii,  p.  578. 
— Eu.] 


HYPERSECRETION   OF  GASTRIC  JUICE.  507 

The  main  diagnostic  features  have  already  been  considered.  At 
present  it  is  not  expedient  to  give  any  points  of  differeiitial  diag- 
nosis ;  this  will  only  be  possible  when  all  are  agreed  as  to  what  is 
understood  under  the  term  Eeichmann's  disease.  It  is  also  impor- 
tant to  bear  in  mind  the  warning  given  by  Boas,*  that  the  find- 
ing of  large  quantities  of  acid  stomach  contents  while  fasting  is  not 
sufficient  to  make  the  diagnosis  of  chronic  gastrosuccorrhoea,  but 
that  the  patient  must  also  have  the  clinical  symptoms  of  this  con- 
dition— i.  e.,  heartburn,  eructation,  occasional  vomiting,  pain  in  epi- 
gastrium and  back,  increased  appetite,  constipation,  and  emaciation  ; 
besides,  the  excessive  quantities  of  hyperacid  gastric  juice  must  be 
of  constant  occurrence. 

The  treatment,  being  different  than  that  of  the  neuroses  in  gen- 
eral, vnll  be  considered  separately.  Bouveret  f  divides  this  into 
several  indications,  of  which  we  may  mention  :  1.  To  stop  the  flow 
of  gastric  juice.  This  may  be  effected  by  lavage  with  a  solution  of 
argentic  nitrate,  O"!  or  0*2  per  cent  as  an  intragastric  spray,  or  150 
to  200  c.  c.  [f  5  V  to  vjss.]  are  introduced  every  other  day,  and  are 
allowed  to  remain  ten  or  fifteen  minutes ;  it  may  also  be  presented 
in  pill  form.  Simple  lavage  has  also  been  recommended.  We  may 
also  give  Carlsbad  salts,  large  doses  of  alkalies,  or  atropine.  My 
own  experience  with  atropine  has  been  favorable.  It  may  be  given 
in  tablets  of  gr.  yi-^-  three  times  daily  after  meals. 

2.  To  suppress  all  causes  of  excitation  of  the  secretory  appara- 
tus. This  includes  mental  quiet,  hydrotherapy,  regulation  of  the 
diet — i.  e.  avoidance  of  salt,  alcohol,  and  highly  seasoned  food.  The 
diet  must  be  so  regulated  that  small  meals  are  given  at  frequent  in- 
tervals ;  albuminoids  should  be  in  excess  ;  starches  and  sugars  are  to 
be  avoided. 

3.  To  combat  the  effects  of  the  excessive  amount  of  HCl,  espe- 
cially of  the  pain,  vomiting,  and  the  dilatation  of  the  stomach. 
These  have  already  been  considered  in  the  previous  chapters.] 

Among  these  neuroses  I  also  classify  the  condition  called  Gas- 
troxynsis  [yaa-T'qp,  stomach,  o^v^,  acid]  by  Rossbach,  which  differs 

*  [Boas.     Zur  Lehre  vom  chronischen  Magensaftfluss.     Berl.  klin.  Wochenschr., 
1895,  No.  46.— Ed.] 

t  [Loe.  cit.,  p.  213.— Ed.] 


508  DISEASES  OF  THE   STOMACH. 

from  migraine  only  in  the  fact  that  it  does  not  occur  spontaneously 
as  frequently  as  the  latter,  but  as  the  result  of  definite  causes,  men- 
tal overexertion  or  profound  emotional  disturbances,  and  that  the 
vomited  masses  are  very  acid,  containing  as  much  as  3"4  to  4  per 
thousand.  However,  the  latter  is  common  to  both  the  condition 
and  typical  migraine,  since  I  have  repeatedly  obtained  equally  high 
results  in  the  latter.  Jiirgensen  *  and  "VYestphalen  have  also  ob- 
served very  similar  states.  [Boasf  considers  that  this  condition 
ought  to  be  included  among  the  periodical  cases  of  hypersecretion.] 
[Dauber  ;{:  has  recently  reported  a  case  of  chronic  continuous  se- 
cretion of  mucus — gastrosuccorrhoea  mucosa.  At  first  the  symp- 
toms were  those  of  a  chronic  catarrhal  gastritis  with  a  moderate 
hyperacidity ;  later  on,  while  expressing  the  stomach  early  in  the 
morning,  he  obtained  60  c.  c.  [f  §  ij]  of  a  turbid  milky  fluid  which 
contained  a  trace  of  BLCl  and  much  mucus.  Fragments  of  food  and 
saliva  were  absent.  Subsequent  examinations  yielded  the  same  re- 
sults. Dauber  considers  this  condition  a  secretory  neurosis  analo- 
gous to  gastrosuccorrhoea.] 

Nervous  Belching,  Eructatio. — It  is  only  in  hysterical  persons  that 
I  have  seen  this  occur  alone,  for  in  neurasthenics  it  is  always  asso- 
ciated with  other  sensations,  especially  oppression  and  tension  in  the 
epigastrium.  I  agree  with  Weissgerber,*  who  has  published  a  very 
exhaustive  paper  on  eructation,  that  in  the  former  [hysteria]  there  is 
a  heightened  contractility  of  the  stomach,  together  with  an  in- 
creased tone  of  the  pylorus,  provided  the  other  manifestations  of 
hysteria  are  also  considered  among  the  processes  of  irritation. 
Since  the  sphincter  at  the  pylorus  is  stronger  than  that  at  the  cardia, 
it  will  contract  more  powerfully  even  if  both  are  equally  stimulated  ; 
hence,  when  the  distention  of  the  stomach  is  so  great  that  it  must 


*  Jiirgensen.  Ueber  Abscheidung  neuer  Formen  nervoser  Magenkrankheiten. 
Deutsch.  Archiv  fur  klin.  Med.,  Bd.  xliii,  S.  9  und  20. — Westphalen.  Kopfschmerzen 
gastrischen  Ursprungs.    Berl.  klin.  Wochenschr.,  1891,  No.  37. 

t  [Boas,  op.  cit.,  Bd.  ii.  p.  132.— Ed.] 

X  [Dauber.  Ueber  kontinuirliehe  Magensehleimsekretion.  Boas's  Arch.,  Bd. 
ii,  p.  168.— Ed.] 

*  Weissgerber.  Ueber  den  Mechanismus  der  Ructus  und  Bemerkungen  iiber 
den  Lufteintritt  in  den  Magen  Neugeborener.     Berl.  klin.  Wochenschr.,  1878,  No.  35. 


NERVOUS  BELCHING.  509 

expel  some  of  its  gas,  tins  can  escape  more  readily  upward  than 
downward.  For  it  can  not  be  doubted  that  eructation  is  an  active 
and  not  a  passive  process.  It  may  be  possible,  as  claimed  by  Stiller 
and  Rosenthal,  that  a  relaxation  of  the  cardia  may  facilitate  the 
exit  of  the  gases  from  the  stomach,  and  that  hence,  according  to  cir- 
cumstances, eructation  may  be  due  either  to  an  increase  or  a  paral- 
ysis of  the  muscular  action  of  the  stomach.  Plowever,  in  many 
cases,  belching  certainly  has  nothing  to  do  with  relaxation  of  the 
cardia,  as  is  shown  by  the  numerous  patients  who  try  in  vain  to 
empty  their  stomachs  of  the  accumulated  gas. 

There  is  another  kind  of  belching  which  is  entirely  independent 
of  the  stomach,  in  which  the  gas  is  raised  only  from  the  oesophagus 
by  contracting  the  muscles  of  the  neck,  just  as  Bristowe  *  has  as- 
sumed in  hysterical  vomiting.  This  form  escaped  Weissgerber's 
notice  entirely.  I  myself  can  belch  voluntarily,  and  I  have  con- 
vinced myself  by  means  of  the  deglutition  murmur  that  the  air 
which  is  compressed  in  the  oesophagus  does  not  enter  the  stomach 
unless  additional  true  movements  of  deglutition  are  executed.  We 
may  therefore  accept  the  fact  that  it  is  possible  to  belch  from  the 
oesophagus  alone,  and  this  may  explain  many  cases  of  hysterical 
eructation  in  which  the  stomach  is  not  distended. 

Belching  may  become  a  very  annoying  symptom,  since  it  is  never 
noiseless  but  is  usually  quite  loud.  In  one  attack,  of  an  hour's  dura- 
tion, Cartellieri  f  was  able  to  count  it  twenty-five  hundred  times ! 
The  gas  is  always  odorless  and  tasteless,  and  thus  differs  in  this  re- 
spect from  that  raised  in  true  dyspepsia,  fermentative  processes,  etc. 
It  therefore  must  consist  of  atmospheric  air  which,  in  the  opinion  of 
most  authors,  must  have  been  swallowed,  but  which  may  also  possi- 
bly come  up  from  the  intestines  ;  in  many  cases  it  is  certainly  raised 
only  from  the  oesophagus.  Cartellieri  says  his  patient  had  no  time 
to  swallow  air  during  the  attack ;  in  such  cases  the  question  then 
arises.  Is  air  really  expelled,  or  is  it  a  manifestation  in  which  this  is 
simulated  ?     So  far  as  I  know,  this  subject  has  never  been  investi- 

*  Bristowe.  Clinical  Remarlcs  on  the  Functional  Vomiting  of  Hysteria.  Prac- 
titioner, 1883,  p.  161. 

f  P.  Cartellieri.  Eine  seltene  vorkommende  Magenneurose.  Wiener  allgemeine 
med.  Zeitung,  1885,  S.  3. 


510  DISEASES  OF  THE  STOMACH, 

gated.  It  is  worthy  of  note  that  I  hare  observed  nervous  eruc- 
tation quite  as  frequently  in  men  as  in  women.  These  cases  are 
always  neurasthenics  in  whom  suggestion  is  of  value. 

Pyrosis  denotes  the  raising  of  sour  masses  from  the  stomach, 
a  symptom  which  is  well  known  under  the  name  of  heartburn.  In 
the  nervous  forms  of  this  condition  at  least,  the  stomach  contents 
are  not  necessarily  hyperacid ;  on  the  other  hand,  severe  acrid  and 
burning  sensations  may  be  produced  by  the  regurgitation  of-  even 
normal  stomach  contents  or  gastric  juice.  Here,  also,  one  may  be  in 
doubt  whether  the  cause  resides  in  a  heightened  contraction  of  the 
muscular  coat  of  the  stomach  or  in  a  paralysis  of  the  cardiac  sphinc- 
ter. I  have  been  led  to  classify  this  phenomenon  among  the  motor 
conditions  of  irritation,  because  I  have  in  vain  searched  for  the  sign 
of  a  marked  relaxation  of  the  cardia,  the  occurrence  of  the  first  deg- 
lutition murmur. 

Next  in  order  is  the  consideration  of  a  very  annoying  condition 
called  Pneumatosis,  or  Tympanites.  Here  the  stomach  is  filled  with 
gas,  and  may  become  so  distended  that  it  causes  not  alone  the  un- 
pleasant sensation  of  marked  tension,  but  even  severe  nervous  symp- 
toms, by  pushing  the  diaphragm  upward  and  pressing  on  the  heart. 
The  patients  are  seized  with  typical  attacks  of  asthma — the  asthma 
dyspepticum  of  Henoch — in  which  at  first  there  is  only  the  annoy- 
ing feeling  of  being  compelled  to  take  deep  inspirations  after 
short  periods  of  normal  breathing ;  at  the  beginning  this  suifices, 
but  later  it  develops  into  an  incessant  dyspnoea.  I^ow  there  is  also 
palpitation  of  the  heart,  pulsation  of  the  peripheral  arteries,  fullness 
of  the  head,  and  even  the  feeling  of  impending  death,  or  com- 
plete unconsciousness — in  short,  such  is  the  condition  that  I  have 
been  repeatedly  told  by  many  sufferers  that  they  were  almost  driven 
to  suicide.  Relief  can  only  be  afforded  by  bringing  up  some  of 
the  gas,  and  then  the  attack  rapidly  subsides.  This  condition  is 
probably  caused  by  the  air  which  has  been  swallowed,  together  with 
a  spasm  of  the  sphincters  of  the  stomach.  The  chemical  processes 
were  normal  in  one  case  which  I  examined,  yet  the  same  state  may 
be  produced  in  dyspeptics  by  the  gas  generated  in  fermentation. 

The  attacks  may  be  relieved  instantly  by  introducing  the  stom- 
ach tube  and  allowing  the  gas  to  escape.     But  it  seems  that  it  is 


NERVOUS  VOMITING.  611 

very  difficult  to  cure  the  disease  itself  where  it  is  nervous  in  char- 
acter.    In  one  case  of  pneumatosis  I  had  no  success  with — 

ip,   Cocain.  hydrochloratis I'D  [gr.  xv] 

Aq.  amygdal.  amarge 10*0  [f  3  ijss.] 

M.    Sig. :  Ten  drops  every  two  hours. 

Large  doses  of  bromide  of  potassium  had  also  been  given,  but 
without  producing  any  effect.  In  another  case  hypodermic  injec- 
tions of  morphine  into  the  epigastrium  gave  immediate  relief ;  a 
third  case  was  cured  by  change  of  climate.  The  patient  was  a  Bra- 
zilian, who  while  at  home  had  suffered  very  severely  from  pneuma- 
tosis, but  here  [Germany]  he  was  entirely  free  from  it. 

Nervous  Vomiting. — This  includes  those  forms  of  vomiting  which 
are  caused  neither  by  anatomical  lesions  of  the  stomach  nor  by 
quantitative  or  qualitative  changes  in  the  food.  It  is  pre-eminently 
reflex,  and  may  be  caused  either  directly  by  the  vomiting  center  or 
indirectly  from  other  points  in  the  central  nervous  system,  or  from 
other  organs.  As  far  as  we  know,  the  causes  of  this  condition  may 
include  palpable  changes  in  the  brain  and  spinal  cord,  kidneys, 
uterus,  liver,  and  certain  organs  of  sense.  These  forms  of  nervous 
vomiting  may  be  classed  among  the  reflex  neuroses. 

I  have  had  the  opportunity  of  observing  two  such  cases  of  nerv- 
ous vomiting  in  close  succession  ;  during  their  course  they  seemed 
to  be  very  much  alike,  yet  the  nature  of  the  primary  affection  caused 
them  to  terminate  very  differently. 

The  first  case  was  a  married  lady,  thirty-six  years  old,  who  had  been 
suffering  for  three  weelfs  with  uncontrollable  vomiting  and  a  continuous 
flow  of  saliva,  tog-ether  with  strong  fetor  from  the  mouth.  This  con- 
dition had  come  on  after  an  attack  of  catarrhal  jaundice,  traces  of  which 
were  just  recognizable  in  a  slight  discoloration  of  the  sclerotics  at  the 
time  I  first  saw  the  patient.  She  had  emaciated  very  little  considering 
that  she  had  taken  scarcely  any  nourishment  during  this  period,  for  she 
vomited  everything  immediately  after  eating.  On  examination,  nothing 
could  be  found  anywhere,  not  even  in  the  liver.  The  passages  were 
loose  and  bright  yellow.  Only  temporary  relief  was  obtained  by  the 
hypodermic  use  of  morphine  with  atropine,  washing  out  the  stomach  with 
chloroform  water,  and  chloroform  internally.  Finally,  the  attacks  were 
controlled  by  withholding  all  food  and  drink  by  the  mouth,  and  using  nu- 
tritive enemata  for  several  days.  But  the  salivation  kejjt  up  some  weeks 
longer,  when  it  ceased  entirely.  The  condition  here  was  probably  a  reflex 
irritation  from  a  gallstone ;  hysteria  was  excluded  because  the  patient 
was  otherwise  healthy  and  the  mother  of  several  grown-up  children.    I 


512  DISEASES  OP  THE  STOMACH. 

must  not  conceal  the  fact  that  for  a  long  time  the  patient  caused  me  a 
good  deal  of  anxiety  on  account  of  the  absence  of  definite  points  on  which 
to  base  a  diagnosis. 

The  second  case  was  a  lady  in  the  fifties,  living  outside  of  Berlin  ;  un- 
fortunately, I  had  the  o^jportunity  of  seeing  her  only  once.  In  the  early 
part  of  1888  she  experienced  profound  emotional  disturbances  ;  since  the 
following  summer  she  had  suffered  from  mild  gastric  troubles  which 
lasted,  with  variable  intensity,  till  November.  After  that  every  meal  was 
regularly  followed  by  vomiting,  which  had  continued  with  few  intermis- 
sions till  the  beginning  of  January,  when  I  saw  the  patient.  The  woman, 
who  had  formerly  been  strong,  was  now  very  much  run  down  ;  she  had 
frequent  attacks  of  unconsciousness,  and  complained  of  great  weakness, 
especially  in  the  legs.  Sleep  was  good.  The  urine  had  been  repeatedly 
examined,  but  albumen  and  sugar  were  not  found. 

I  found  a  bedridden  patient  who  was  still  quite  well  nourished  in  spite 
of  the  emaciation  she  complained  of  ;  she  could  move  quite  readily  in  the 
bed  ;  she  spoke  with  deliberation  ;  in  short,  she  seemed  less  affected  than 
was  to  be  expected  from  her  history.  On  examination  I  could  find  noth- 
ing but  a  struma,  and  tachycardia  up  to  one  hundred  and  twenty  beats 
per  minute.  There  was  no  tumor  nor  any  tenderness  in  the  abdomen. 
Patellar  reflexes  normal  ;  pupils  reacted  well ;  no  limitation  of  the  field  of 
vision,  and  no  complaints  about  sight.  Sensation  everywhere  normal. 
Heart  and  lungs  negative. 

In  my  presence  the  patient  ate  two  pieces  of  toast  and  drank  a  glass  of 
water  without  vomiting.  The  tube  was  easily  introduced  and  the  stomach 
contents  expressed  twenty-five  minutes  after.  No  hydrochloric  acid 
found  ;  the  fragments  of  toast  were  scarcely  digested.  This  result  left  the 
diagnosis  in  doubt  between  a  severe  neurosis  and  an  occult  carcinoma ; 
yet  the  absence  of  true  cancerous  cachexia  favored  the  former.  The 
rapidity  of  the  pulse  was  attributed  to  the  struma ;  tabes  accompanied 
by  gastric  crises  was  excluded  on  account  of  the  absence  of  its  specific 
symptoms. 

The  condition  seemed  to  improve  at  first  by  using  nutritive  enemata 
and  restricting  feeding  by  the  mouth  as  much  as  possible  ;  small  doses  of 
digitalis  and  atropine  were  also  given.  But  she  soon  relapsed  into  the 
old  condition  ;  she  gradually  grew  weaker,  till  one  day  she  was  seized 
with  epileptic  convulsions  and  died  several  days  later.  An  autopsy  was 
not  allowed,  yet  the  whole  clinical  picture  led  me  to  diagnosticate  an  af- 
fection of  the  medulla  oblongata,  probably  a  tumor,  involving  the  roots 
of  the  vagus,  thus  causing  the  persistent  vomiting  and  the  rapid  pulse. 
At  all  events,  this  presupposes  such  a  situation  of  the  suspected  tumor 
that  the  nucleus  of  the  fibers  of  the  vagus  distributed  to  the  heart  was 
paralyzed  or  destroyed,  while  those  fibers  going  to  the  stomach  were  kept 
in  a  condition  of  chronic  irritation.  The  soundness  of  this  supposition 
remains  in  doubt,  although  it  is  by  no  means  without  a  parallel  (Ro- 
senthal). 

Both  of  these  cases  are  typical  examples  of  severe  vomiting 
caused  by  nervous  irritation,  and  at  the  same  time  they  show  how 


NERVOUS  VOMITING.  513 

difficult  (sometimes  even  impossible)  it  is  to  make  a  diagnosis  at  a 
given  time  during  life. 

For  a  certain  group  of  cases  we  are  unable  to  find  this  proof, 
althougb  we  may  suspect  the  reflex  origin.  Pre-eminent  among 
these  stands  the  vomiting  of  neurasthenic  and  hysterical  patients  ; 
it  is  uncommon  among  the  former,  but  occurs  frequently  in  the 
latter.  It  is  characteristic  of  this  form  of  vomiting  that  it  usually 
occurs  without  any  true  nausea,  and  that  the  retching  is  reduced  to  a 
minimum.  Hysterical  vomiting  may  occur  after  every  meal ;  some- 
times it  is  less  frequent.  Either  all  food  may  be  rejected,  or  only 
certain  kinds  or  even  individual  dishes.  I  made  use  of  this  fact  in 
making  my  first  investigations  on  the  course  of  normal  digestion  in 
human  beings  ;  my  subject  was  a  hysterical  girl  who  could  retain 
all  kinds  of  solid  food,  but  was  compelled  to  vomit  whenever  she 
swallowed  any  fluid.  Another  young  girl,  who  has  now  been  under 
my  observation  for  a  number  of  years,  regularly  vomits  nearly  all 
that  she  has  eaten  almost  immediately  after  every  meal.  The  gen- 
eral nutrition  suffers  surprisingly  little  from  this  persistent  vomit- 
ing ;  thus  the  second  patient's  weight  has  been  almost  the  same 
during  the  past  four  years ;  she  has  come  down  from  40 '5  to  39*5 
kilogrammes  (89  to  87  pounds).  In  other  cases  the  vomiting  does 
seem  to  affect  the  weight.  Thus  Tuckwell  *  reports  that  three  chil- 
dren were  very  greatly  emaciated  after  prolonged  vomiting  which 
lasted  for  months  ;  it  was  controlled  by  sitting  the  little  patients  up 
as  soon  as  any  tendency  to  vomiting  occurred  (and  also,  to  be  sure, 
carefully  regulating  the  diet).  Barrasf  speaks  of  a  woman  who 
suffered  from  nervous  vomiting,  but  who  ceased  to  vomit  while  she 
was  in  the  bath ;  she  was  cured  after  her  meals  were  given  to  her 
in  this  way. 

This  affection  may  pursue  an  acute  or  chronic  course ;  it  may 
begin  spontaneously  or  may  follow  some  demonstrable  cause.  One 
young  girl  was  attacked  immediately  after  the  death  of  her  father ; 
another  as  the  result  of  breaking  off  an  engagement  of  marriage. 
As  in  other  neuroses,  the  female  sex  is  especially  liable. 

I  must  confess  that  my  experience  of  the  infrequent  occurrence 

*  Tuckwell.     On  Vomiting  of  Habit.     British  Med.  Journal,  March  23,  1873. 
f  Barras.     Traite  sur  les  gastralgies  et  enteralgies.     Paris,  1837. 


514:  DISEASES  OP  THE  STOMACH, 

of  vomiting  in  neurasthenics  does  not  agree  with  that  of  Eosenthal, 
who  claims  to  have  seen  it  not  infrequently  in  this  class  of  patients. 
I  shall  simply  content  myself  with  giving  the  headings  of  two  of 
his  histories : 

Observation  No.  31. — Neurasthenia,  hypersesthesia  toward  acids,  with 
consecutive  gastric  colic  and  vomiting.  Cured  by  local  remedies  (small 
pieces  of  ice,  with  two  to  three  drops  of  tincture  of  nux  vomica)  and  gen- 
eral invigorating  treatment. 

Observation  No.  32. — Neurasthenia  following  onanism,  with  frequent 
vomiting.  After  the  latter  had  ceased  it  began  again  after  each  coitus, 
while  a  heavy  meal  did  not  cause  any  complaints.  Neurasthenia  and 
vomiting  cured  by  prohibiting  sexual  intercourse  at  the  beginning  of  the 
treatment,  increasing  doses  of  potassium  bromide,  with  some  pyrophosph. 
ferri  citronatric.  [Ph.  Austr.],  Neptune's  girdle,  galvanization  of  the  sym- 
pathetic, and  hydriatic  procedures. 

This  difference  in  observation  might  appear  striking,  yet  it  may 
be  readily  explained  by  the  fact  that  two  observers  in  places  at 
some  distance  from  each  other  [Berlin  and  Yienna]  deal  with  dif- 
ferent kinds  of  patients.  Concerning  the  multiplicity  and  intensity 
of  all  neuroses  it  is  peculiar  that  they  most  frequently  attack  the 
easily  excitable  Southerners,  and  especially  the  nationalities  living 
near  the  military  border.  Hypersecretion  seems  also  to  occur  more 
frequently  there  than  in  Germany. 

Finally,  I  must  speak  of  a  form  of  nervous  vomiting  which  was 
described  by  Leyden.*  It  may  occur  as  a  primary  neurosis,  or  as  a 
secondary  spinal  affection,  or  as  a  reflex  form.  A  peculiarity  of  this 
variety  is  the  periodicity  of  the  attacks  [whence  the  name  periodical 
vomiting],  which  may  last  from  a  few  hours  to  a  number  (ten)  of 
days.  They  begin  with  sudden  nausea  and  colicky  contractions  of 
the  intestines,  but  the  abdominal  wall  is  relaxed.  At  first  the  vomit 
consists  of  food  debris  and  slimy  masses,  later  of  bile  and  streaks 
of  blood ;  the  attacks  accompanied  by  migraine  and  tearing  sensa- 
tions in  the  limbs  ;  they  are  followed  by  obstinate  constipation, 
which  is  due  to  a  spasm  of  the  intestine.  The  trouble  may  last  for 
years,  but  its  origin  can  only  be  sought  in  the  directions  indicated 
above.     In  two  of  my  cases  the  autopsies  gave  negative  results. 

*  Leyden.  Ueber  periodisches  Erbrechen  (gastrische  Krisen)  nebst  Bemerk- 
nngen  liber  nervosa  MagenaflEectionen.  Zeitschr.  fiir  klin.  Mediein,  1882,  Bd.  iv, 
S.  605. 


STOMACH   COLICS.  515 

[Kelling  *  has  recently  reported  a  case  of  periodical  vomiting 
associated  with  diarrhoea  and  vasomotor  disturbance  whicli  was 
hereditary ;  the  patient  was  a  woman,  forty-two  years  old,  whose 
grandmother  and  mother  suffered  in  the  same  way.  The  attacks 
were  brought  on  by  emotional  disturbances  and  were  not  relieved 
by  any  drug  except  morphine,  which,  however,  only  slightly  de- 
layed and  lessened  the  attacks.  The  urine  passed  during  the  parox- 
ysms was  more  acid  and  toxic  than  that  passed  afterward.] 

Stomach  colics  are  usually  included  among  the  gastralgias.  In 
fact,  they  frequently  occur  together,  since  stomach  colic  is  accom- 
panied by  severe  pains.  But,  as  indicated  by  the  name,  the  pains 
are  colicky,  and  are  due  to  a  spasmodic  contraction  of  the  viscus ; 
but  they  are  not  boring  and  shooting,  as  in  genuine  gastralgias. 
The  causal  factors  are  the  same  as  those  which  have  been  described 
under  the  gastralgias. 

Localized  spasms  may  occur  at  the  cardia  and  pylorus.  While 
introducing  the  stomach  tube  we  sometimes  experience  the  sensation 
as  if  the  instrument  were  spasmodically  gripped  at  the  cardia.  It 
would  be  difficult  to  ascertain  whether  this  is  due  to  a  contraction 
of  the  lower  segment  of  the  oesophagus  or  of  the  cardia. 

Spasm  of  the  pylorus  seems  to  be  due,  disregarding  the  irritation 
from  local  changes,  to  gastric  juice  which  is  either  too  acid  or 
which  has  been  secreted  at  improper  times.  This  is  the  only  way 
of  explaining  hyperacidity  and  hypersecretion,  as  has  been  sug- 
gested by  Boas  and  myself.  Hanssen  f  describes  a  case  of  spastic 
stenosis  which  produced  a  palpable  tumor  at  the  pylorus  the  size  of 
a  thumb,  and  which  disappeared  under  a  soothing  treatment. 

In  distention  of  the  stomach  with  gas,  its  escape  upward  or 
downward  can  only  be  prevented  by  an  abnormally  tight  closure  of 
the  gastric  sphincters. 

Peristaltic  Unrest  of  the  Stomach  {Peristaltische  Unruhe,  Tor- 
mina ventriculi  nervosa). — This  was  first  described  by  Kussmaul  X 
as  being  causel  by  an  increased  peristalsis,  which  is  so  intense  and 

*  [Kelling.     Zeitschr.  fiir  klin.  Med.,  Bd.  xxix,  p.  421.— Ed.] 
f  Hanssen.     Quoted  in  Virchow-Hirsch's  Jahresber.  fiir  1890,  p.  241. 
X  Kussmaul.     Volkmann's  Sammlung  klinische  A'ortrage,  1880,  No.  181.    [Also 
Boas,  Deutsch.  med.  Wochenschr.,  October  17,  1889. — Ed.] 


516  DISEASES  OF  THE  STOMACH. 

SO  well  marked  tliat  it  may  readily  be  perceived  tlirougli  tlie  relaxed 
abdominal  parietes,  and  wliicli  may  at  times  be  accompanied  by 
gurgling  and  rumbling  loud  enough  to  be  heard  at  a  distance.  This 
affection,  by  itself,  is  not  painful,  yet  it  may  torture  the  sufferer  to 
extremes.  "  It  is  just  as  if  the  intestines  were  twisted  around  in- 
side my  abdomen,"  was  told  to  me  recently  by  a  female  patient, 
forty-six  years  of  age,  in  whom  the  noises  in  the  gut  were  so  marked 
that  they  were  audible  as  soon  as  she  entered  the  room.  They  are 
most  intense  after  meals,  yet  they  do  not  disappear  entirely  between 
them ;  and,  like  other  neuroses,  they  have  the  characteristic  pecul- 
iarity that  they  sometimes  suddenly  cease  when  the  patient  becomes 
excited — for  example,  during  the  doctor's  visit — although  a  moment 
before  they  were  present  in  full  intensity.  Kussmaul's  earliest  cases 
were  persons  with  gastrectasis,  and  the  majority  of  the  cases  which 
have  since  been  observed  have  been  such  patients. 

The  reverse  of  this  condition,  antiperistaltic  unrest  of  the  stom- 
ach, has  been  observed  by  Glax  *  as  a  pure  neurosis.  His  was  a 
typical  case ;  the  examples  which  had  previously  been  published  by 
Schiitz  and  Cohn  were  not  free  from  criticism.  Glax's  case  was  a 
man,  thirty-two  years  old,  who  had  formerly  suffered  from  dyspep- 
tic disturbances  and  a  slight  dilatation  of  the  stomach ;  the  writer 
describes  his  condition  as  follows  : 

A  shallow  but  distinct  constriction  could  be  seen  passing  vertically- 
downward  over  the  stomach  from  the  right  sternal  border.  Suddenly  to 
the  left  of  this  the  fundus  ventriculi  appeared  hard  and  tense,  and  grad- 
ually expanded  to  the  size  of  a  child's  head ;  this  swelling  slowly  went 
down,  then  appeared  to  the  right  of  the  constriction,  and  then  began 
almost  immediately  to  the  left  again.  Often,  however,  the  movement 
distinctly  passed  from  the  right  back  to  the  left  in  an  antiperistaltic 
direction.  I  then  distended  the  stomach  with  carbonic  acid  gas,  which 
caused  the  movements  to  become  very  active. 

Errors  may  arise  from  the  not  infrequent  occurrence  of  peri- 
staltic unrest  of  the  intestines ;  this  may  also  assume  an  antiperistaltic 
form.  That  this  may  actually  happen  is  shown  by  the  cases  of  Bri- 
quet, Jaccoud  and  Fouquet,  and  Rosenstein,  in  which  scybalse  and 
discolored  enemata  were  evacuated  through  the  mouth. f     In  many 

*  Glax,  loc.  ciL,  p.  190. 

t  [A  case  of  habitual  defecation  by  the  mouth  has  been  reported  by  Desnos 
(Wiener  med.  Presse,  1891,  No.  51,  S.  1958).     The  case  was  that  of  a  man  who 


POLYPHAGIA.  517 

persons  stroking  the  finger  nail  rapidly  and  sharply  across  the  epi- 
gastrium will  produce  distinct  peristaltic  movements. 

Here  we  must  also  include  the  cases  of  hyperkinesis  of  the  stom- 
ach — i.  e.,  increased  motor  activity — which  causes  the  chyme  to  pass 
on  into  the  intestines  too  soon.  In  such  cases  the  stomach  is  found 
absolutely  emj)ty  one  hour  after  the  test  breakfast,  and  water  which 
is  introduced  through  the  tube  returns  practically  without  any  frag- 
ments of  the  roll.  The  same  is  true  of  the  larger  test  meals.  This 
is  usually  associated  with  an  increased  secretion  of  HCl.  Leo  *  and 
Weinert  f  have  endeavored  to  construct  a  new  disease  out  of  these 
cases.  Such  cases  I  have  seen  and  described  years  ago.:}:  It  is  an 
open  question  whether  the  cause  is  only  an  increase  in  the  motor 
functions  and  an  abnormally  rapid  solution  and  absorption  of  the 
food,  or  whether  it  is  due  to  an  insufficiency  of  the  pylorus. 

II.  Conditions  of  Depression. 

Concerning  the  conditions  of  anaesthesia  of  the  stomach  we  know 
very  little,  or  rather  it  would  be  truer  to  say,  practically  nothing. 
In  Chapter  IX  attention  was  drawn  to  this  point ;  and  as  we  nor- 
mally have  no  perception  of  the  processes  going  on  in  and  about 
our  stomachs,  we  can  not,  therefore,  gain  any  distinct  conceptions 
of  a  pathological  lack  of  sensitiveness. 

Polyphagia,  or  acoria  [a,  without,  Kopeto,  I  satiate],  the  want  of 
the  feeling  of  satiation,  is  best  regarded  as  a  result  of  ansesthesia  of 
the  stomach. 

If  in  the  discussion  on  bulimia  and  anorexia  I  have  made  it  evi- 
dent that  these  conditions  are  due  to  an  overexcitation  of  centers  in 
the  braui,  then  satiation  must  be  considered  an  inhibition  of  hunger, 

was  found  on  the  street  in  an  epileptic  attack;  the  saliva  which  flowed  from  the 
mouth  was  apparently  mixed  with  fecal  matter.  Upon  inquiry,  the  patient  said 
that  for  two  years  he  had  not  passed  his  stools  pe?-  anwn,  but  at  six  o'clock  each 
evening  he  passed  a  stool  by  his  mouth.  The  man  was  under  observation  only  two 
days,  but  his  statement  was  corroborated.  At  times  the  evacuation  took  place 
without  any  effort ;  at  others  they  occurred  during  a  nervous  attack,  with  slight 
convulsions  and  pain  in  the  CBsophagus. — Ed.] 

*  Leo.     Ueber  Bulimie.    Deutsch,  med,  Wochenschr.,  1889. 

f  Weinert.  Ein  seltener  Fall  von  Hyperkinese  des  Magens.  Inaug.  Dissert., 
Berlin,  1892. 

:j:  Ewald,     Diseases  of  the  Stomach.     Translated  by  Manges,  p.  435. 


518  DISEASES  OP  THE  STOMACH. 

and  the  absence  of  this  sensation  a  negative  phenomenon — ^i,  e., 
either  the  hunger  center  is  no  longer  under  the  influence  of  the 
nervous  paths  passing  to  it,  or  the  latter  are  defective.  But  I  have 
already  shown  the  vagueness  and  uncertainty  of  all  such  deductions, 
which  still  lack  a  tangible  and  well-established  basis,  and  I  believe 
this  is  also  true  of  the  above  suggestions. 

Purely  nervous  polyphagia  is  a  very  rare  occurrence  ;  naturally 
I  exclude  those  gluttons  of  whom  the  old  and  new  books  on  "  gas- 
trosophy  "  are  full ;  but  I  mean  those  really  morbid  conditions  which 
usually  follow  tangible  lesions,  and  in  the  discussion  of  which  these 
cases  will  be  found, 

Hervous  anacidity  (or  anachlorhydria)  of  the  gastric  juice  is  not  as 
rare  as  it  would  appear  after  searching  through  the  literature.  I 
have  repeatedly  found  it  in  hysterical  persons  (see  the  case  of  hys- 
terical gastralgia,  page  498).  I  have  also  observed  it  in  neurasthen- 
ics in  whom  there  was  no  reason  for  suspecting  an  organic  disease 
of  the  stomach.     I  shall  restrict  myseK  to  the  following  case  : 

Mr.  P.,  landed  proj)rietor  in  Culm,  a  powerful  man  of  Herculean  build, 
forty-three  years  of  age,  said  that  he  had  been  very  nervous  since  the 
death  of  his  wife ;  he  imagined  that  he  had  a  cancer  of  the  stomach ;  there 
were  also  abnormal  sensations  in  the  urethra  and  impaired  sexual  pow- 
ers. His  appetite  was  absent ;  the  stools  were  constipated,  hard,  and  dry. 
His  disposition  was  exceedingly  melancholic. 

On  examination,  nothing  could  be  found  except  a  very  marked  sensi- 
tiveness of  the  spinal  column  on  pressure  against  the  spinous  processes 
and  with  the  faradic  brush.  The  stomach  and  urinary  tract  (catheteriza- 
tion) were  found  normal.  Examination  of  the  test  breakfast  after  ex- 
pression revealed  the  absence  of  free  acid.  He  was  admitted  to  the  sani- 
tarium, where  he  slej)t  after  taking  potassium  bromide.  Hydrochloric  acid 
was  also  given,  as  well  as  lukewarm  baths  in  the  morning  and  warm  rub- 
bings in  the  evening.  He  was  kept  under  observation  nearly  two  months, 
and  in  that  time  the  stomach  contents,  after  the  test  breakfast,  were  ex- 
amined five  times  at  about  weekly  intervals.  They  were  always  neutral, 
and  contained  the  breakfast  almost  without  any  changes,  but  there  was 
no  mucus. 

Gradually  the  condition  improved,  after  all  kinds  of  sensations  in  the 
soles  of  the  feet,  loins,  larynx,  and  urethra  had  in  the  meanwhile  ap- 
peared. He  was  advised  to  go  to  the  hydriatic  establishment  at  Elgers- 
burg,  where  he  stayed  several  weeks.  Later  on  I  received  a  report  from 
there  that  "  Mr.  P.,  the  neurasthenic,  who  leaves  here  to-day,  has  been 
generally  improved  by  the  use  of  lukewarm  half-  and  sitz-baths,  elec- 
tricity, and  massage  ;  yet,  in  spite  of  this,  his  old  complaints  have  re- 
turned, etc." 


NERVOUS  ANACHLORHYDRIA.  519 

Recently  I  heard  again  from  this  patient.  Although  a  year  and  a 
half  have  elapsed,  his  symptoms  are  about  the  same.  There  are  no  signs 
of  real  loss  of  strength.  We  may  therefore  exclude  organic  diseases,  car- 
cinoma, mucous  catarrh,  etc. 

I  have  observed  quite  a  number  of  similar  cases  of  even  longer 
duration,  one  of  wliich  which  was  of  particular  interest,  I  have  pub- 
lished.* The  following  is  another  case  which  is  also  a  good  example 
of  the  relation  between  nervous  dyspeptic  conditions  to  the  true 
psychoses  (see  page  499). 

Mr.  K.,  an  actor,  twenty-eight  years  old  ;  slender  figure.  Previous 
history  good  ;  no  organic  diseases  can  be  discovered.  He  was  always  in 
good  health,  and  lived  quietly  and  regularly.  In  the  winter  of  1884-'85  he 
had  to  play  a  very  exciting  part  several  hundred  times  in  succession  at 
one  of  the  local  [Berlin]  theatres.  He  felt  exhausted  and  languid  till  in 
the  following  summer  his  condition  became  as  follows,  to  use  his  own 
words  : 

"  It  seemed  to  me  as  if  my  entire  abdomen  was  constricted  with  a  cord, 
so  that  suddenly  I  was  attacked  with  a  feeling  of  anxiety  ;  there  was  also 
oppression  which  extended  high  up  into  the  chest  and  caused  a  torment- 
ing dyspncea.  I  could  not  take  a  long,  deep  breath,  on  account  of  the 
feeling  of  undue  fullness  in  the  abdomen.  This  condition  persisted  even 
when  I  had  eaten  nothing — e.  g..  on  awakening  early  in  the  morning.  I 
can  not  complain  of  any  real  pains,  yet  I  have  never  felt  really  well 
since.  The  pressure  in  the  abdomen  and  the  oppression  following  it  con- 
tinually reminded  me  that  my  health  was  shattered.  Although  I  fre- 
quently had  a  good  appetite  and  relished  food,  yet  not  alone  after  eating, 
but  even  during  the  meal,  severe  disturbances  set  in,  combined  with  end- 
less belching  and  eructation,  and  great  fatigue  ;  in  the  beginning  there 
was  also  vomiting,  but  after  a  few  times  this  did  not  return.  At  times  I 
was  suddenly  seized  with  a  ravenous  appetite,  after  the  satiation  of  which 
the  above  attacks  did  not  fail  to  appear. 

"  The  family  physician's  remedies  were  all  of  no  avail,  and  this  condi- 
tion persisted  till  the  winter  of  1886.  Then  the  discovery  that  I  had  a 
tape-worm  gave  me  hope  that  with  its  removal  I  would  be  cured.  But, 
alas  !  even  after  that,  the  old  state  persisted,  and,  if  anything,  became 
worse.  My  arduous  duties  in  the  winter  of  1886-'87  did  not  cause  the 
trouble  to  be  less  marked.  Since  then  every  part  of  my  body  feels  very 
tired  and  languid,  and  in  spite  of  careful  rest  and  forbearance  this  has 
persisted  up  to  the  present  time.  The  pressure  from  the  distended  abdo- 
men, oppression  (frequently  also  stitches  in  the  side),  and  dyspnoea  still 
persist.  In  spite  of  this  I  still  have  an  appetite,  sometimes  a  very  large 
one.  I  usually  relish  food,  but  after  meals,  as  a  rule,  though  not  always, 
the  unpleasant  symptoms  make  their  appearance,  and  are  more  marked  at 
some  times  than  at  others."' 

*  Ewald.     Ein  Fall    ehronischer  Secretiousuntuchtigkeit  des  Magens.     Berl. 
kiln.  Woehenschr.,  1892,  No.  26. 
34 


520  DISEASES  OF  THE  STOMACH. 

I  have  treated  this  gentleman  a  long  time,  and  have  tested  his  gastric 
juice  for  hydrochloric  acid  twenty-nine  times,  at  the  most  varied  intervals 
after  the  test  breakfast,  and  also  after  a  more  abundant  dinner.  A  small 
amount  of  free  acid  could  be  detected  only  three  time's.  Propeptone  was 
always  present  in  relatively  large  quantities,  but  the  peptone  reaction  was 
only  faii}t,  and  the  digestive  power  of  the  filtered  gastric  contents  was 
negative,  except  in  two  tests,  unless  liydr'ochloric  acid  and  pepsin  were 
added.  The  rennet  action  could  be  demonstrated  in  half  of  the  tests,  and 
that,  too,  in  the  absence  of  free  hydrochloric  acid,  but  at  the  same  time 
lactic  acid  was  present ;  at  other  times  the  tests  for  lactic  acid  and  peptone 
were  positive,  although  free  muriatic  acid,  pepsin,  and  rennet  were  all 
absent.  Much  mucus  were  never  present  in  the  wash- water  except  the 
first  time,  when  the  patient  had  evidently  swallowed  large  quantities, 
which  were  due  to  the  irritation  of  the  tube.  On  the  other  hand,  on 
two  occasions  I  found  small  shreds  which  differed  from  those  usually 
present  in  the  wash-water,  by  sinking  rapidly  in  the  funnel.  They  con- 
sisted of  the  adherent  epithelial  cells  of  the  gastric  mucous  membrane 
already  described  (see  Fig.  27).  Although  I  consider  this  pathological, 
yet  such  abrasions  continually  occur  in  the  mucosa  of  the  stomach  as  well 
as  in  other  mucous  membranes,  though  they  are  usually  not  found,  since 
the  acid  gastric  juice  digests  them.  Strychnine  was  first  given  in  small 
doses  ;  then  later  on  his  stomach  was  washed  out  and  douched  every  sec- 
ond day  with  good  results.  In  this  case  there  was  surely  no  mucous  ca- 
tarrh; an  atrophy  of  the  mucosa  was  also  absent,  since  this  occurs  only 
as  the  consequence  of  a  long-standing  catarrh,  or  at  a  much  more  advanced 
age.  None  of  the  symptoms  indicate  cancer ;  what  is,  therefore,  left  but 
to  assume  that  we  are  dealing  with  a  neurosis  ? 

The  subsequent  course  of  the  case  proved  the  correctness  of  my  diag- 
nosis. The  patient  went  to  a  well-known  establishment  for  nervous  dis- 
eases, and  then  spent  a  long  time  in  Switzerland.  On  his  return  the 
gastric  symptoms  had  completely  disappeared,  and  in  his  own  eccentric 
way  he  could  not  say  too  much  in  favor  of  his  cure. 

But  he  now  frequently  had  attacks  of  melancholia.  The  following 
summer  he  went  to  the  country  near  a  large  lake.  One  evening  he  left 
the  house  and  never  returned.  His  body  was  found  in  the  rushes  at  the 
border  of  the  lake ;  he  had  evidently  committed  suicide  by  drowning. 

The  case  was  thus  a  neurosis  which  had  at  first  attacked  the  vegeta- 
tive functions,  and  finally  had  involved  the  mind. 

I  have  already  given  my  opinion  on  the  significance  of  the  ab- 
sence of  free  hydrochloric  acid  [p.  343  et  seq.']. 

Relaxation  of  the  eardia  and  of  the  pylorus  must  be  considered 
conditions  which  resemble  paralysis. 

Paresis  of  the  eardia  may  give  rise  to  the  annoying  and  trouble- 
some nervous  eructation  (see  above,  under  Eructation,  page  508). 
If  fluids  or  remnants  of  food  are  raised,  as  well  as  gas,  the  condition 
is  called  regurgitation.     In  very  many  persons  small  quantities  oi 


RUMINATION.  521 

chyme  having  a  very  sour  taste  are  raised  after  eating,  but  they  are 
swallowed  at  once ;  this  condition  can  Le  called  neither  pathological 
nor  very  annoying.  But  if  it  occurs  frequently,  and  if  larger  quan- 
tities are  regurgitated,  then  they  are  no  longer  swallowed  again  but 
are  expectorated ;  true  rumination,  such  as  occurs  in  animals,  does 
not  take  place.  This  condition  is  very  annoying  and  may  lead  to 
serious  changes  in  nutrition,,  yet  it  may  also  exist  for  years  without 
any  bad  results.  At  times  will-power  may  succeed  in  repressing  it ; 
yet  I  have  seen  a  young  man  in  whom  neither  will-power  nor  large 
doses  of  bromide  of  sodium  had  any  effect. 

Regurgitation  also  occurs  in  diverticula  of  the  oesophagus ;  here 
it  may  be  due  either  to  the  filling  up  of  the  diverticulum  and  its 
overflowing  into  the  mouth — this  occurs  most  frequently  when  there 
is  a  stricture  below  the  site  of  the  diverticulum — or  the  contents  of 
the  pouch  may  voluntarily  be  raised,  or  rather  pressed  upward,  by 
the  patient. 

At  my  lectures  I  have  frequently  presented  a  patient  with  a  diverticu- 
lum who  was  able  to  raise  its  contents  at  will  by  taking  a  deep  inspiration 
and  beai'ing-  down.  As  he  restricted  himself  to  fluids,  the  matei'ial 
which  he  raised  contained  no  solid  substances ;  the  greater  part  of  it 
was  mucus,  and  by  its  smell  one  could  ascertain  whether  he  had  pre- 
viously taken  coffee,  alcoholic  drinks,  etc.  The  reaction  was  alkaline  or 
neutral.  At  first  there  was  no  odor,  but  recently  the  patient  has  ob- 
served that  what  he  regurgitates  has  a  slight  foul  smell. 

An  entirely  different  thing,  is  Rmnination,  Merycismus  [/jLrjpvKd^G), 
I  ruminate],  which  has  attracted  the  attention  of  laymen  and  phy- 
sicians ever  since  antiquity,  and  has  given  rise  to  the  strangest 
theories.  Some  supposed  that  ruminators  were  necessarily  de- 
scended from  parents  with  horns ;  *  thus  Fahricius  says,  "  Ex  quo 
forte  datur  nobis  intelhgi  parentis  semen  aliquam  habuisse  affini- 
tatem  cum  comigeris  animahbus  neqtie  mirum  fuisse  genitum  filium 
simile  quid  a  parente  contraxisse"  (that  is,  the  father  is  said  to 
have  had  a  horn  on  his  forehead) ;  others  imagined  that  these 
persons — at  least  as  infants — must   have  suckled  ruminating  ani- 

*  I  have  taken  these  data  from  the  following  treatises  :  Bourneville  and  Seglas, 
Arehlv  de  neurologie,  1883,  p.  86  ;  Schmidtmann,  loc.  cit.,  p.  183 ;  Schneider,  Das 
"Wiederkauen  beim  Menschen,  Heidelberger  nied.  Annalen,  1846,  sii,  S.  251 ;  A. 
Johannesen,  Ueber  das  Wiederkauen  beim  Menschen,  Zeitschrift  fiir  klin,  Med., 
Bd.  X,  S.  274. 


522  DISEASES  OF  THE   STOMACH. 

mals*;  or  even  that  "  the j  had  sinful  intercourse  with  a  co^T." 
For  a  long  time  the  opinion  prevailed  that  these  persons  certainly 
had  stomachs  with  different  compartments,  like  ruminants,  till  it 
was  finally  shown  by  autopsies  that  in  the  majority  of  cases  there 
were  no  changes  in  the  stomach  or  oesophagus. 

As  time  passed  by  these  negative  results  became  more  frequent ; 
but  Schneider  [1846]  was  able  to  report  the  case  of  a  court  coun- 
cilor from  Fulda  who  had  died  at  the  age  of  seventy  years,  at  the 
end  of  the  previous  century,  after  having  ruminated  all  his  life.  In 
this  case  it  was  found  that  the  cardia  was  wide  enough  to  easily  ad- 
mit five  fingers,  and  that  the  stomach  was  enormously  dilated. 
Arnold  (1838)  observed  three  cases  of  rumination  in  which  a  sac- 
culated dilatation  of  the  oesophagus  was  found  above  the  cardia 
in  the  antrum  cardiacum.  Boumeville  and  Seglas  f  (1883)  came  to 
the  conclusion  that  there  was  no  real  anatomical  change. 

In  fact,  the  manifestations  of  rumination  are  especially  liable  to 
attract  attention.  'Not  alone  is  it  remarkal)le  that,  a  shorter  or 
longer  interval  after  eating,  the  food  returns  to  the  mouth  in  sep- 
arate morsels,  unchanged  in  taste,  to  be  chewed  and  swallowed  a 
second  time,  yet  it  is  still  more  wonderful  that  they  should  come 
up  in  a  definite  order,  and  that  they  should  taste  even  better  than 
the  first  time  ; :{:  or  that  the  taste  may  be  so  unchanged  that,  as  re- 
ported by  Peter  Frank,  a  patient  could  distinguish  the  food  in  the 
reverse  order  in  which  he  had  eaten  it  on  the  previous  day.  It  is 
also  stated  by  Darwin  that  any  particular  dish  which  had  been 
eaten  could  be  regurgitated  at  pleasure.  This  certainly  seems  to 
be  almost  superhuman.  J^o  light  is  shed  by  the  explanation  of 
Gallois  *  that  the  regurgitated  masses  at  first  consist  of  an  indis- 
tinguishable mixture  of  fluid  and  solid  ingesta ;  but  when  rumina- 
tion occurred  during  the  later  stages  of  digestion  they  would  then 
contain   only  solids,  and   finally  merely  indigestible   remnants  of 

*  Daniel  Perinetti,  an  eight-year-old  child,  was  said  to  have  been  nourished  by 
a  goat  for  two  years,  and  to  have  ruminated  later  on  in  imitation  of  it. 

f  Archiv  de  neurologie,  1883. 

I  Anthony  Reehy  said,  "  Indeed,  it  is  sweeter  than  honey,  and  accompanied  by 
a  more  delightful  relish." 

*  P.  Gallois.  Merycisme  et  etude  physiologique  de  la  digestion  stomaeale. 
Revue  de  mcd.,  1889,  No.  3. 


RUMINATION.  523 

food,  like  tendon's,  leaves  of  salad,  etc.  A  simple  explanation,  is 
that  during  gastric  digestion  the  fluidified  ingesta  are  removed 
from  the  stomach ;  hence,  the  regurgitated  masses  gradually  con- 
tain more  and  more  solid  substances  which  can  not  be  attacked 
by  the  stomach,  and  finally  consist  of  nothing  but  the  latter. 
Hence,  the  condition  of  the  regurgitated  food  does  not  depend  on 
the  wishes  of  the  patient,  but  upon  the  phase  of  digestion  in  which 
rumination  occurs.  Eossier  *  asked  one  of  these  subjects  to  keep 
a  record  of  the  number  of  the  regurgitated  morsels.  After  break- 
fast there  were  six  to  twelve ;  dinner,  eleven  to  twenty-one ; 
supper,  seven  to  sixteen. 

Rumination  must  not  be  confounded  mth  the  condition  in 
which  healthy  persons  may  at  will  regurgitate  the  contents  of  the 
stomach ;  this  is  simply  due  to  their  ability  to  expel  food  from  the 
stomach  in  the  same  manner  as  in  my  method  of  expression.  It 
was  this  fact,  for  example,  which  led  Montegre  f  to  make  his  in- 
vestigations on  digestion. 

That  rumination  is  due  to  a  neurosis  is  beyond  doubt.  This  is 
corroborated  by  the  well-authenticated  cases  of  heredity — e.  g., 
"Windthier's  case  of  a  Swede,  forty-five  years  of  age,  who  had 
ruminated  since  his  thirtieth  year ;  his  son  also  began  it  in  his 
twenty-fourth  year.  Bossier  describes  a  father  and  son,  sixty-five 
and  twenty -four  years  old  respectively.  Another  factor,  imitation, 
may  play  an  important  part ;  this  is  shown  in  the  case  reported  by 
Korner,:}:  where  a  ruminating  governess  gave  it  to  her  two  pupils. 
Additional  weight  is  lent  by  its  relatively  frequent  occurrence  in 
nervous  persons  suffering  from  neurasthenia,  hysteria,  epilepsy,  and 
idiocy,  and  its  cessation  when  the  patients  experience  profound 
emotional  disturbances — passion,  anger,  etc.  The  case  of  Ducasse  * 
also  confirms  this ;  this  was  a  young  man  who  had  been  afflicted 
with  this  disorder  from   his  sixth  to  twenty-eighth   year;    it  was 

*  Rossier,  Mercyeisme  hereditaire  dependant  d'une  cpilopsie.  Annal.  do  la 
Soc.  de  med.  d'Anvers.  avril-mai,  1867. 

f  Montegre.     Experiences  sur  la  digestion.     Paris,  1814. 

X  0.  Korner.  Beitriige  zur  Kenntniss  der  Rumination  beim  Menschen.  Deutsch. 
Arehiv  fiir  klin.  Med.,  Bd.  xxxiii. 

*  Ducasse.  Mem.  de  I'Acad.  royals  de  Toulouse,  tome  iii.  Quoted  by  Schnei- 
der, loc.  cit. 


524  DISEASES  OF  THE  STOMACH. 

lessened  on  the  first  day  after  his  marriage,  and  disappeared  one 
week  after ;  in  other  cases  the  reverse  has  occurred ;  there  are  still 
others  in  whom  the  malady  is  made  worse  by  sexual  excesses. 

The  state  of  nutrition  of  the  patients  is  very  variable.  The  dis- 
ease may  occur  in  all  classes  of  society  and  at  all  ages.  Haste  in 
eating  and  the  swallowing  of  large  morsels  seem  to  be  of  very  fre- 
quent occurrence  in  this  disorder.  Rumination  may  take  place 
voluntarily  or  involuntarily,  but  its  suppression  causes  pain. 

The  most  varied  speculations  have  been  indulged  in  as  to  its 
cause :  first  a  central  lesion  was  suggested ;  then  a  peripheral  one ; 
some  thought  it  was  due  to  a  relaxation  of  the  cardia ;  others  re- 
ferred it  to  a  heightened  sensibility  of  the  mucosa  and  stronger  mus- 
cular contractions  of  the  stomach,  or  even  to  some  peculiar  forma- 
tion of  the  latter  or  of  the  antrum  cardiacum  of  the  CESophagus. 
We  must  confess  that  we  really  know  nothing  of  the  true  etiology 
of  the  affection,  and  it  would  simply  be  a  circumlocution  to  follow 
the  example  of  Dehio,*  who  designates  it  a  "  perverse  and  com- 
bined act  of  motion  "  or  a  reflex  functional  neurosis.  A  study  of 
the  murmurs  of  deglutition  shows  that  there  can  be  no  permanent 
relaxation  of  the  cardia.  Dehio  heard  in  his  patient  a  distinct 
second  deglutition  murmur  "  which,  according  to  the  generally  ac- 
cepted view  of  the  origin  of  this  murmur,  can  not  be  present  when 
the  cardia  is  ]3aralyzed"  [see  footnote,  p.  93].  Distention  of  the 
stomach  with  carbonic-acid  gas  also  showed  that  the  cardia  was 
competent.  In  two  cases  of  my  own  in  which,  at  all  events,  rumi- 
nation was  not  very  marked  (possibly  eructation  would  be  the 
proper  name),  repeated  examination  failed  to  reveal  the  normal 
deglutition  murmurs.  According  to  the  prevailing  views,  this 
would  also  speak  against  a  permanent  relaxation  of  the  cardia ;  on 
the  other  hand,  no  further  proof  is  needed  to  show  that  at  the  time 
of  rumination  the  tone  of  the  cardiac  sphincter  must  be  relaxed,  and 
that  there  must  be  a  paresis,  or,  better,  an  unusually  easy  yielding 
of  the  cardia.  [Singer  f  believes  that  the  relaxation  of  the  cardia  is 
due  to  the  mechanical  dilatation  of  the  lower  portion  of  the  oesoph- 

*  K.  Dehio.     Ein  Fall  von  RuminaUo  humana.     St.  Petersburger  med.  Woch- 
enschr.,  1888,  No.  1. 

t  [G.  Singer.     Deutsch.  Archiv  fur  klin,  Med.,  Bd.  1.— Ed.] 


RUMINATION".  525 

eo^us  which  results  from  swallowino-  too  lar^e  morsels.  This  dilata- 
tion  can  be  demonstrated  with  the  oesophagoscope.]  Unfortunately, 
in  the  patient  who  was  able  to  swallow  two  live  goldfish,  respec- 
tively 6^  and  5^  centimetres  [2f  and  2^  inches]  long,  and  to  regurgi- 
tate them  alive  twenty  minutes  after,  Alt  *  neglected  to  study  the 
murmurs  of  deglutition ;  yet  this  performance  would  seem  almost 
impossible  without  a  relaxation  of  the  cardia  and  oesophagus,  since 
it  is  scarcely  possible  that  the  delicate  fish  could  have  been  squeezed 
through  the  narrow  passage  alive.  Decker  rej)orts  five  cases  in 
which  the  stomach  was  repeatedly  inflated ;  as  the  cardia  was 
always  found  to  be  competent,  the  possibility  of  a  permanent  paraly- 
sis or  paresis  of  the  cardia  is  excluded. 

The  chemical  processes  in  the  stomach  have  been  studied  by 
Alt,  Boas,  Jiirgensen,  Sievers,  Leva,  Decker  [and  Ilunge].f  The 
variable  results  obtained — all  degrees  of  acidity,  from  hyperacidity 
to  anacidity,  were  found — agree  with  the  statement  I  made  that  "  the 
changes  in  the  chemical  processes  of  the  stomach  are  not  an  essential 
but  only  an  incidental  feature  in  the  symptomatology  of  rumination  • 
hence  1  would  not  be  at  all  surprised  if  in  one  and  the  same  patient 
varying  degrees  of  acidity  were  found  under  otherwise  identical 
conditions,  since  such  a  variable  relation  is  characteristic  of  many  of 
the  neuroses."  This  latter  supposition  has  since  been  verified  by 
Leva,  who  found  all  the  various  degrees  of  secretion  of  HCl  in  a 
ruminant. 

Nevertheless,  among  the  cases  just  referred  to  relief  was  ob- 
tained by  the  treatment  which  was  indicated  by  the  results  of  the 
chemical  examhiations ;  alkalies  were  given  in  one  case  of  Alt  and 
three  cases  of  Sievers,  where  there  was  hj^racidity,  and  acids  in 
Boas's  case  with  subacidity.  These  results  should  be  appreciated  still 
more,  since  every  kind  of  treatment  which  had  previously  been  tried 
was   unsuccessful.      The  only  exception  to  this  was   Eossier,  who 

*  K.  Alt.  Beitriige  zur  Lehre  von  Merycismus.  Berl.  klin.  Wochensehr.,  1888, 
Nos.  26  and  37. 

f  Alt,  he.  cit. — Boas.  Berl.  klin.  Wochensehr.,  1888,  No.  30. — Chr.  Jiirgensen. 
Ibid.,  No.  36.— Sievers.  Finske  Lakares  Allskapt,  1889.— Leva,  Munch,  med.  Woch- 
ensehr., 1890,  Nos.  20.  31.— Decker.  Ibid..  1893,  No.  31.— Freyhan.  Dentsch.  med, 
Wochensehr.,  1891,  No.  41.— Einhorn.  Medical  Record,  May  17, 1890.— [Runge.  St. 
Louis  Medical  Review,  August  18,  1894. — Ed.] 


526  DISEASES   OF   THE   STOMACH, 

gave  relief  in  one  case  by  tlie  internal  administration  of  morphine  in 
increasing  doses  up  to  40  centigrammes  [gr.  vj]  a  day ;  in  another 
patient  in  whom  this  drug  was  powerless  he  succeeded  with  large 
doses  of  opium,  1-5  gramme  [gr.  xxijss.].  In  general,  the  best 
treatment  seems  to  be  that  given  in  a  case  described  by  Ponsgen — an 
energetic  will,  and  swallowing  the  food  at  once  when  it  regurgitates, 
without  chewing  it  a  second  time.  Expectoration  of  the  regurgi- 
tated food  may  lead  to  serious  disturbance  of  nutrition,  as  occurred 
in  the  case  reported  by  Sauvage,  of  a  patient  who  had  been  afflicted 
for  thirty  years,  but  whose  confessor  had  ordered  him  to  spit  out 
the  regurgitated  masses.  Two  weeks  later  he  had  emaciated  very 
much,  but  he  did  not  improve  till,  at  the  advice  of  a  physician,  he 
returned  to  the  old  habit. 

If  the  existence  of  paresis  of  the  cardia  in  rumination  is  an  as- 
sumption rather  than  a  demonstrated  fact,  this  is  even  more  appli- 
cable to  incontinence  of  the  pylorus,  which  was  considered  a  special 
nervous  affection,  first  by  L.  de  Sere,*  and  more  recently  by  Eb- 
stein.f  It  is  true  that  the  latter  has  positively  demonstrated  that 
the  pylorus  may  be  incompetent  when  unyielding  neoplasms  involve 
this  portion  of  the  stomach ;  this  was  naturally  to  be  expected,  but 
unfortunately  we  have  no  diagnostic  criteria  by  which  we  may  es- 
tablish the  existence  of  this  condition  as  dependent  upon  atony  of 
the  pyloric  sphincter — i.  e.,  as  a  pure  neurosis — for  an  occasional 
incontinence  of  the  pylorus  is  a  normal  phenomenon.  An  extensive 
experience  will  demonstrate  to  any  one  what  was  first  observed  by 
Kussmaul,  that,  after  introducing  the  tube  into  the  stomach  while 
fasting,  intestinal  contents  or  bile  may  be  obtained  ;  this  occurs  most 
frequently  when  the  patients  have  gone  without  eating  for  a  longer 
period  than  usual.  The  natural  inference  from  this  is  that  the  pylo- 
rus was  not  firmly  closed ;  consequently  it  will  be  very  difficult  to 
distinguish  its  pathological  occurrence  from  the  physiological.  Fur- 
thermore, Ebstein's  diagnostic  test,  the  rapid  passage  into  the  intes- 
tines of  the  carbonic-acid  gas  which  has  been  artificially  generated 

■*■  L.  de  Sere.     Du  relachement  du  pylore.     Gaz.  des  hop.,  1864,  No.  62. 

t  Ebstein.  Ueber  Nichtschlussfahigkeit  des  Pylorus  (Incontinentia  pylori). 
Volkmann's  klin.  Vortrage,  No.  155. — Einige  Beinerkungen  zu  der  Lehre  von  der 
Nichtschlussfahigkeit  des  Pylorus.  Deutsch.  Archiv  fur  klin.  Med.,  Bd.  xxxvi, 
S.  295. 


ATOXY  OF  STOMACH.  527 

in  the  stomacli,  is  unreliable,  and  is  subject  to  many  errors.  First, 
tlie  inflation  of  the  stomach  may  displace  some  coils  of  intestines  up 
against  the  abdominal  wall,  just  as  if  they  had  been  distended  by  the 
passage  of  gas  into  them  from  the  stomach ;  secondly,  different  per- 
sons require  very  varying  quantities  of  effervescing  powder  to  dis- 
tinctly inflate  their  stomachs ;  finally,  the  gastric  contents  may  com- 
bine with  more  or  less  of  the  gas  as  it  is  generated.  Hence  the 
pylorus  may  be  competent,  in  spite  of  the  negative  result  of  this  test. 

At  all  events,  incontinence  of  the  pylorus  is  a  very  rare  occur- 
rence. In  the  numerous  cases  in  which  I  have  distended  the  stom- 
ach to  its  utmost  with  air,  I  could  never  distinctly  demonstrate  such 
a  condition;  instead  of  that,  the  air  always  escaped  U23ward  with  ex- 
plosive eructations  whenever  the  tension  became  too  great.  ]^ever- 
theless,  I  beheve  that  some  dyspeptic  disturbances  are  due  to  pyloric 
incontinence  ;  yet  many  more  are  the  result  of  regurgitation  of  the 
intestinal  contents  into  the  stomach  rather  than  a  too  early  passage 
of  the  chyme  into  the  duodenum.  On  the  other  hand,  I  agree  fully 
with  Ebstein  and  Zeckendorf,*  that  the  acute  intestinal  tympanites 
of  hysterical  persons  may  be  largely  due  to  the  rapid  passage  from 
the  stomach  into  the  intestines  of  air  which  has  been  swallowed  ; 
hence  the  pylorus  must  necessarily  have  been  incompetent. 

Atony  of  the  stomach  is  an  important  neurosis  to  which  sufficient 
attention  has  not  yet  been  paid.  We  have  already  encountered 
this  condition  and  its  results  as  an  accompanying  symptom  of 
manifold  dyspeptic  disturbances  ;  but  atonic  states  of  the  gastric 
musculosa  may  undoubtedly  occur  as  a  primary  neurosis,  as  an  inde- 
pendent disorder  of  the  innervation  of  the  nerve  centers  regulating 
the  peristalsis  of  the  stomach ;  these  may  occur  either  hi  loco  affec- 
tio7iis  or  in  the  central  nervous  system,  and  are  frequently  the  cause 
of  the  dyspeptic  troubles  resulting  therefrom.  It  is  superfluous  to 
speak  in  detail  about  the  origin  of  this  condition  as  a  result  of  in- 
sufficient or  too  tardy  movement  of  the  chyme,  since  we  have  already 
frequently  observed  this  reciprocal  relation  of  cause  and  effect.  I 
simply  wish  to  distinctly  state  once  more  that  I  consider  "  atony " 
to  include  a  disturbance  of  the  gastric  motor  function  only,  not  of 


*  Zeckendorf.     Ueber  die  Pathogenese  der  Bauchtympanie.     Dissertation,  Got- 
tingen,  1883. 


528  DISEASES  OF  THE  STOMACH. 

its  secretory ;  in  other  words,  it  is  a  lack  of  agreement  between  tlie 
muscular  force  of  tlie  stomacli  and  the  task  to  be  accomplished  by 
it — i.  e.,  it  is  an  insufficiency  of  the  stomach  (Rosenbach).  Other- 
wise we  may,  like  Yon  Pfungen,*  include  three  fourths  of  all  the 
lesions  of  the  stomach  under  this  title,  and  yet  not  obtain  a  clear 
conception  of  its  relations. 

Atony  may  be  partial  or  complete,  depending  upon  the  involve- 
ment of  the  fundus  or  pylorus  or  the  entire  stomach.  I  consider 
this  classification  premature,  for  it  is  based  upon  the  independence 
of  the  several  portions  of  the  stomach,  which  has  recently  been  re- 
peatedly maintained.  I  will  admit  the  value  of  the  experiments  of 
Schiff,  von  Hofmeister,  and  Schiitz  upon  the  movements  of  the 
stomachjf  and  also  the  observations  of  Yon  Pfungen :{;  upon  a  pa- 
tient who  had  undergone  the  operation  of  gastrotomy  ;  according  to 
these  experiments,  the  motor  power  of  the  body  of  the  stomach  is 
about  one  third  as  great  as  that  of  the  antrum  pylori ;  while  the 
function  of  the  latter  is  especially  to  expel  the  chyme,  that  of  the 
former  is  the  trituration  of  the  ingested  food.  But  I  maintain  that 
we  know  so  little  about  the  movements  of  the  stomach  in  patho- 
logical cases  that  we  may  be  happy  to  be  able  even  to  recognize  the 
existence  of  these  disturbances  as  such.  Furthermore,  I  can  not  see 
what  is  gained  by  such  a  distinction  between  atony  of  the  pyloric 
portion  and  of  the  body  of  the  stomach  ;  for,  so  far  as  clinical  effects 
are  concerned,  the  latter  will  always  be  the  more  important  and 
causal  factor.  Where  there  is  no  movement  in  the  body  of  the 
stomach  its  absence  can  not  be  replaced  by  the  peristalsis  of  the  an- 
trum pylori,  be  the  latter  ever  so  powerful ;  but  if  a  normal  or  even 
heightened  peristalsis  of  the  fundus  be  associated  with  an  atonic 
condition  of  the  pyloric  portion,  there  can  be  no  obstruction  to  the 
expulsion  of  the  chyme ;  on  the  other  hand,  this  must  be  more  easily 
accomplished  than  normally,  since  an  atonic  state  of  this  portion  of 
the  musculosa  of  the  stomach  would  be  inconceivable  without  a  co- 
incident diminution  of  the  tone  of  the  true  pyloric  sphincter  which 

*  R.  Preiherr  v.  Pfungen.     Ueber  Atonie  des  Magens.     Klinisehe  Zeit-  und 
Streitfragen.     Vienna,  1887. 

f  Vide  Bwald.     Klinik,  etc.,  I.  Theil,  3te  Auflage,  S.  78. 
X  Log,  cit,  p.  261. 


NEURASTHENIA   GASTRICA.  529 

is  so  closely  associated  with  it ;  consequently,  the  muscular  power  of 
the  remainder  of  the  stomach  can  easily  overcome  the  resistance  of 
the  "  inert  channel  "  thus  formed.  In  such  cases  we  might  possibly 
suppose  that  where  this  relaxation  of  the  pyloric  portion  begins  a 
closure  of  some  kind  might  be  effected  by  the  contraction  of  the 
adjacent  circular  fibers  of  the  stomach,  and  thus  none  of  the  chyme 
will  pass  on  into  the  intestines  in  spite  of  the  apparently  vigorous 
peristalsis.  This  is  how  Von  Pfungen  attempts  to  explain  a  case  of 
this  kind  which  had  been  reported  by  KussmauL*  Such  suppo- 
sitions, however,  lead  us  into  the  broad  field  of  speculation,  from 
which  we  must  keep  aloof  as  far  as  possible. 

III.   Mixed  Foem  of  Gastric  j^eueoses. 

Neurasthenia  Gastrica  (Nervous  Dyspepsia). — The  condition  which, 
under  the  name  of  nervous  dyspepsia,  has  recently  been  the  subject 
of  so  much  discussion,  is,  in  my  opinion,  only  a  complex  form  in 
which  the  neuroses  already  described  in  the  preceding  pages  take  a 
more  or  less  prominent  part,  but  which  is  at  the  same  time  charac- 
terized by  an  active  participation  of  the  entire  gastro- intestinal  tract. 

According  to  Leube,f  nervous  dyspepsia  is  a  group  of  symptoms 
essentially  of  a  cerebral  nature,  which  are  due  to  an  abnormal  irri- 
tability of  the  sensory  nerves  of  the  stomach  toward  the  normal 
digestive  processes,  and  which  are  especially  manifested  by  the 
symptoms  which  I  have  already  grouped  together  among  the  sen- 
sory phenomena  caused  by  irritation. 

On  the  other  hand.  Stiller  includes  under  this  title  of  nervous 
dyspepsia  all  those  conditions  in  which  there  is  a  predominance  of 
digestive  disturbances  which  are  reflected  back  upon  the  stomach 
from  and  by  means  of  the  central  nervous  system  and  the  sym- 
pathetic respectively,  and  which  may  incidentally  cause  definite 
changes  in  its  functions.  Whereas  the  former  writer  proceeds  from 
the  center  of  the  circle  to  the  periphery,  the  latter  goes  in  the  re- 
verse direction,  from  the  periphery  to  the  center.  Furthermore, 
while  the  former  claims  that  the  true  peptic  activity  of  the  stomach 

*  Kussmaul.     DeiUsch.  Arch,  fiir  klin.  Med.,  Bd.  vi,  p.  470. 
f  Leube.     Ueber  nervose   Dyspepsie.     Deutsch.  Arch,  fiir  klin.  Med.,  Bd.  xxiii, 
1879.     Also  Spec.  Diagnostik  der  innerer  Krankheiten.     3te  Auflage,  1891,  p.  265. 


530  DISEASES   OF   THE  STOMACH. 

is  unchanged,  the  latter  maintains  that  it  is  altered  under  certain 
conditions,  and,  in  fact,  in  the  majority  of  cases. 

In  this  dilemma  it  would  be  difficult  to  follow  the  usual  course 
and  say  that  the  truth  lies  midway  between  these  two  views,  for  in 
a  certain  sense,  or  rather  with  certain  restrictions,  both  of  them  may 
be  correct.  There  are  some  cases — i.  e.,  the  rarer  cases  of  Leube — 
which  correspond  to  the  picture  of  nervous  dysj^epsia  ;  but  I  believe 
that  this  group  will  gradually  grow  smaller  and  smaller  with  the 
increasing  delicacy  of  the  methods  of  investigating  the  peptic  pow- 
ers of  the  stomach.  After  a  careful  study  of  the  digestive  pro- 
cesses, I  have  found  changes  in  the  chemical  functions  in  quite  a 
large  number  of  cases  in  which  the  nervous  symptoms  were  the 
prominent  feature.  Furthermore,  we  must  not  forget  that  our  pres- 
ent methods  of  chemical  examination  are  still  relatively  crude,  and 
give  us  absolutely  no  information  concerning  the  amount  of  pepsin 
secreted,  and  very  httle  about  the  intensity  of  absorption  and  the 
strength  of  motion.  Hence,  we  can  only  ascertain  certain  gross 
changes,  while  there  is  surely  quite  a  large  number  of  alterations 
which  escape  us  because  they  lie  beyond  our  present  limits.  The 
same  may  be  true  of  anatomical  changes.  Important  discoveries  of 
this  kind  have  been  reported  by  Jiirgens,  Blaschko,  and  Sasaki. 
Jiirgens*  has  made  an  important  contribution  upon  this  point.  In 
forty-one  patients  who,  while  alive,  had  complained  of  vague  dysr 
peptic  disturbances,  a  complete  degeneration  of  Meissner's  and 
Auerbach's  plexuses  was  discovered  ;  in  this  way  he  gave  a  tangible 
anatomical  basis  to  these  cases  of  dyspepsia,  many  of  which  had 
been  diagnosticated  as  "reflex  dyspepsia."  Furthermore,  "where 
the  disturbance  was  more  of  a  sensory  character,"  he  found  "  a  de- 
generation of  the  muscularis  mucosae  of  the  stomach  and  of  the 
intestines  also,  and  a  pronounced  formation  of  varices  in  the  intes- 
tinal walls,  the  exact  examination  of  which  revealed  a  degeneration 
not  alone  of  the  muscular  fibers  of  the  veins,  but  also  of  the  sensory 
nerves  and  of  the  branches  of  Meissner's  plexus  in  the  vicinity." 
Inasmuch  as  severe  forms  of  anaemia  are  also  accompanied  by  gas- 
tro-intestinal  symptoms  which  are  unusually  pronounced,  especially 

*  Jiirgens.    Verhandlungen  des  iii.  Congresses  fiir  innere  Mediein,  S.  253. 


NEURASTHENIA  GASTRICA.  531 

at  the  beginning  of  the  disease,  and  may  thus  simulate  nervous  dys- 
pepsia, the  findings  of  Blaschko  and  Sasaki  are  of  importance.  In 
severe  anaemias  both  of  these  observers  have  found  marked  degener- 
ation of  the  nervous  plexuses  of  the  intestines,  and  at  times  also  fatty 
degeneration  of  intestinal  muscular  layers  and  atrophy  of  the 
mucosa. 

On  the  other  hand,  in  the  majority  of  cases  we  can  discover  no 
changes  in  the  nerves  outside  of  the  stomach,  of  a  direct  or  reflex 
nature,  which  may  be  referred  to  this  viscus,  or  may  give  rise  to 
immediate  disturbances  of  the  gastric  digestion. 

In  either  case  the  clinical  symptoms  of  this  condition  will  always 
consist  of  the  manifestations  which  I  have  already  described  as  those 
of  irritation  or  paralysis,  a  mosaic  in  which  now  one  stone,  now 
another,  will  be  lacking ;  sometimes  one,  sometimes  another,  will 
be  especially  prominent ;  but  they  will  never  be  firmly  fijced  to- 
gether, and,  like  man  himself,  will  always  jDresent  a  kaleidoscopic 
picture.  There  is  only  one  characteristic  feature,  that,  taken  all  in 
all,  the  symptoms  are  usually  mild,  and  severe  forms  of  gastralgia 
and  cramps,  nervous  vomiting,  polyphagia,  and  bulimia  do  not 
occur. 

In  all  these  patients  the  symptoms  of  imperfect  intestinal  diges- 
tion will  always  be  found  associated  with  those  due  to  changes  in  the 
gastric  functions.  In  some  cases  the  symptoms  of  imperfect  intes- 
tinal digestion  are  not  well  marked,  and  are  restricted  to  the  conse- 
quences of  lessened  or  increased  peristalsis — ^usually  constipation,  less 
frequently  diarrhoea — or  the  stools  may  be  normal  but  absoi-ption  is 
disturbed ;  such  patients  will  emaciate  continuously  in  spite  of  a  good 
appetite,  etc.  Not  very  long  ago  attention  was  directed  to  these 
cases  by  Mobius.*  In  other  cases  the  intestinal  symptoms  are  so 
well  marked  that  one  might  be  tempted  to  group  them  into  a  dis- 
tinct class,  as  was  done  by  Cherchewsky.f  Here,  along  with  mild 
gastric  disturbances,  we  observe  anorexia,  repugnance  toward  taking 
food,  coated  tongue,  mild  nausea — in  short,  symptoms  which  might 


*  P.  Mobius.  Ueber  nervosa  Verdauiingsschwache  des  Barms.  Centralblatt 
fur  Nervenheilkunde  von  Erlenmeyer,  vii.  Jahrgang,  1884,  No.  1. 

f  Cherchewsky.  Contribution  a  la  pathologie  des  nevroses  intestinales.  Eevue 
de  medecine,  1884,  No.  3. 


632  DISEASES  OP  THE  STOMACH. 

not  inaptly  be  designated  those  of  visceral  neuralgia.  Tlie  bowels 
are  usually  constipated,  and  tliere  are  severe  pains  in  the  abdomen, 
either  spread  diffusely  or  recognizable  as  separate  ppanful  spots. 
Rarely  the  abdomen  is  retracted  ;  as  a  rule,  it  is  quite  distended  and 
tympanitic,  sometimes  even  to  a  marked  degree,  while  the  free  es- 
cape of  flatus  causes  great  torture  to  the  sufferer.  The  gas  which 
may  escape  either  by  mouth  or  by  rectum  has  caused  this  condition 
to  be  called  flatulent  dyspepsia.  In  addition  there  are  also  general 
nervous  symptoms  like  those  observed  in  the  gastric  form,  except 
that  they  are  usually  more  severe  and  even  at  times  alarming.* 

If  one  will  recall  what  was  said  in  the  introduction  to  this  part 
about  the  innervation  of  the  stomach  and  intestines,  the  mutual 
transition  of  the  symptoms  of  these  viscera  ought  to  occasion  no 
surprise.  The  close  connections  of  the  numerous  plexuses  of  the 
intestines  and  the  fibers  of  the  vagi,  splanchnics,  and  the  various 
sympathetic  ganglia,  necessarily  cause  the  involvement  of  the  one  to 
be  followed  by  a  disturbance  of  the  other,  no  matter  whether  the 
cause  is  located  centrally  or  peripherally. 

Therefore  I  have  proposed  the  name  neurasthenia  gastrica,  or 
vago-sympathica,  for  this  entire  group  of  symptoms.  It  may  be  sub- 
divided into  a  gastric  and  an  intestinal  form,  according  to  the  viscus 
which  is  especially  involved.f  I  consider  this  name  is  much  better 
than  the  expression  "  nervous  dyspepsia,"  because  it  corresponds 
more  closely  to  the  nature  of  the  affection,  and  my  liking  for  the 
latter  designation  has  by  no  means  been  lessened  by  the  reasons 
given  by  Leyden :{:  in  a  splendid  paper  on  this  theme.  But  we  must 
not  forget  that  the  term  "  nervous  dyspepsia  "  is  so  expressive  and 
in  such  general  use  that  it  may  safely  be  retained. 

As  I  have  already  said,  gastric  neurasthenia  is  a  complex  of  the 
various  nervous  disturbances  already  described,  and  therefore  these 
can  give  no  specific  and  characteristic  data. 

The  same  is  true  of  the  etiology.     Undoubtedly  there  are  cases 

*  One  of  my  patients  wrote  to  me  that  "  I  must  complain  most  of  a  feeling  of 
oppression  while  walking,  bitter  taste  in  the  mouth,  and  obstinate  constipation." 
The  bitter  taste  in  the  mouth  is  frequently  replaced  by  an  exceedingly  annoying 
dryness  and  burning  sensation. 

f  Ewald.     Verhandlungen  des  iii.  Congresses  fiir  innere  Medicin. 

X  E.  Leyden.     Ueber  nervose  Dyspepsie.     Berl.  klin.  Wpchenschr.,  1885,  No.  30. 


NEURASTHENIA  GASTRICA.  533 

in  which  no  cause  can  be  discovered — Fen  wick  *  claims  this  for  the 
majority  of  his  observations — but  surely  there  are  very  few  patients 
indeed  in  whom  the  characteristics  of  a  nervous  disposition  can  not 
be  discovered.  Either  nervous  diseases  are  hereditaj-y  in  the  family^ 
or  the  nervous  system  has  been  very  severely  taxed  in  some  way  or 
another — profound  emotional  excitement,  business  cares,  severe 
mental  exertion,  sexual  excesses — or  the  condition  which  we  call 
cerebral  or  spinal  irritation,  or  any  other  affection  of  the  nervous 
system  bordering  upon  hysteria,  has  preceded  it.  Thus,  I  have  had 
under  my  treatment  for  a  long  time  a  young  man,  eighteen  years 
old,  whose  father  suffered  from  pronounced  spinal  irritation.  An- 
other case  was  an  old  gentleman  who  had  all  the  symptoms  of  a 
well-marked  neurosis  of  the  intestinal  tract,  after  having  suffered 
for  years  from  peculiar  nervous  symptoms,  which  were  always  asso- 
ciated with  irregularities  of  intestinal  digestion.  There  are  also 
some  cases — their  number  is  very  limited — in  which  intestmal  neu- 
roses are  developed  without  these  prodromata.  By  watching  such 
patients  for  a  longer  period  we  will  usually  be  able  to  observe  other 
neurasthenic  symptoms.  I  have  frequently  seen  a  young  lady  in 
whom  the  condition  which  at  first  could  only  be  called  gastric  neur- 
asthenia was  aggravated  on  account  of  the  cessation  of  men- 
struation, and  finally  became  hysteria,  with  especial  prominence  of 
the  signs  of  gastralgia  and  enteralgia.  However,  such  an  occurrence 
is  manifestly  very  rare,  and  warrants  the  suspicion  that  it  was  hys- 
teria from  the  beginning ;  in  fact,  all  these  conditions  now  under 
discussion  were  formerly  included  under  this  disease.  Naturally, 
they  have  been  known  for  a  long  time,  but  their  exact  description, 
and  the  chemical  demonstration  of  the  integrity  of  the  gastric 
juice,  is  an  achievement  of  recent  times,  due  especially  to  the  labors 
of  Leube. 

At  this  place,  however,  I  should  like  to  state  that  the  same  nerv- 
ous conditions  which  constitute  the  prodromata  of  the  dyspeptic 
condition  may  also  become  very  prominent  during  the  course  of  the 
latter.  IS^ot  alone  are  there  pains  in  the  head  and  back,  weariness 
of  the  limbs,  etc.,  but  these  patients  are  very  gloomy  and  pessimis- 

*  Fenwick.     On  Atrophy  of  the  Stomach  and  on  the  Nervous  Aflfections  of  the 
Digestive  Organs.     London,  1880. 


534  DISEASES  OF  THE  STOMACH. 

tic,  worry  unnecessarily,  and  lose  what  little' ambition  they  still  pos- 
sess. One  of  my  patients  complained  of  a  weak  memory  and  in- 
ability to  concentrate  his  thoughts ;  another  suffered  very  severely 
from  vertigo  during  every  exacerbation  of  his  dyspepsia.  At  the 
same  time  the  pulse  became  small  and  rapid,  the  hands  and  feet 
were  cold  and  livid,  and  trembled,  there  was  palpitation  of  the 
heart  with  oppression  and  dyspnoea,  which  became  worse  on  getting 
up  or  walking ;  these  symptoms  increased  to  a  most  intense  fear  of 
impending  death,  till  suddenly  relief  was  brought  by  the  passage  of 
flatus.  Although  the  patient,  who  was  a  well-educated  gentleman, 
moving  in  the  highest  circles,  knew  how  the  attack  would  end,  he 
was  nevertheless  utterly  unable  to  overcome  the  feeling  of  impend- 
ing death.  A  description  by  Freud  *  is  quite  typical,  and  agrees 
very  well  with  my  own  experiences : 

A  patient,  who  was  originally  healthy,  committed  the  usual  sexual 
errors  at  puberty,  overworked  while  a  student,  acquired  a  gonoi'rhcBa,  and 
was  then  suddenly  attacked  with  dyspepsia  accompanied  by  obstinate 
constipation.  He  was  relieved  of  the  latter  after  months,  and  then  had 
oppression  in  the  head  ;  was  moody,  and  unable  to  do  any  work  ;  the  char- 
acter changed,  he  grew  intensely  egotistical,  and  finally  became  a  great 
burden  to  his  family. 

Here  we  continually  encounter  fresh  surprises  and  apparently 
the  most  wonderfully  various  moods  of  the  stomach.  Many  patients 
can  only  retain  ice-cold  fluids,  but  at  once  vomit  the  same  fluids  if 
they  are  slightly  warmed.  Others  have  peculiar  idiosyncrasies  to- 
ward special  articles  of  diet  which  cause  them  the  most  intense 
pain.  Thus  one  of  my  patients,  a  young  man  eighteen  years  old, 
was  completely  absorbed  in  regulating  the  choice  and  quantity  of 
his  food : 

About  midday  he  became  so  weak  that  he  could  not  eat,  and  the  very 
thought  of  food  caused  palpitation  and  cold  sweats.  He  continually  had 
the  sensation  of  a  lump  in  his  stomach.  For  days  weakness  compelled 
him  to  lie  on  the  sofa.  In  the  evening  he  ate  (as  he  thought)  too  much. 
He  was  always  constipated,  and  every  cathartic  made  him  feel  very  weak. 
He  kept  a  voluminous  diary  about  himself.  As  a  youth  masturbated  a 
great  deal,  and  overworked  himself  mentally.  Was  cured,  although  the 
condition  had  lasted  a  number  of  years. 

*  S.  Freud.  Ein  Fall  von  hypnotischer  Heilung,  etc.  Zeitschr.  fiir  Hypnotis- 
mus,  1893,  Heft  3,  p.  103. 


NEURASTHENIA   GASTRICA.  535 

I  have  already  called  attention  to  the  fact,  which  I  shall  empha- 
size once  more,  that  many  of  these  patients  gradually  weaken  them- 
selves to  such  a  degree  by  adhering  too  long  to  a  rigorous  diet 
which  was  necessary  for  a  gastric  catarrh,  etc.,  but  which  was  not  dis- 
continued at  the  proper  time,  that  very  energetic  measures  are  neces- 
sary to  restore  the  normal  tone  of  the  weakened  nervous  system. 

In  all  these  cases  I  wish  to  state  emphatically  that  the  lesions  are 
dyspeptic  conditions  upon  a  neurotic  basis,  never  concomitant  symp- 
toms of  really  demonstrable  injuries  of  the  central  nervous  system — 
e.  g.,  gastric  crises  of  tabes  dorsalis,  diffuse  and  localized  cerebral 
lesions,  ailments  of  the  peripheral  nerves,  etc. ;  or  what  may  occur  as 
reflex  neuroses  in  chlorosis,  menstrual  disorders,  uterine  and  ovarian 
diseases,  and  intense  psychical  excitement  (when  they  are  manifested 
as  nervous  diarrhoea  or  constipation).  As  opposed  to  the  chronic 
and,  if  I  may  so  express  it,  the  milder  character  of  gastric  neuras- 
thenia, these  conditions  take  the  shape  of  acute,  rapidly  developed 
attacks,  accompanied  by  very  intense  symptoms,  which  may  either 
occur  once  or  return  periodically.  Such  attacks  are  described  in 
Richter's  monograph.*  Leydenf  has  also  published  a  series  of  very 
well  marked  examples.  In  my  opinion  the  only  relation  which  they 
bear  to  neurasthenia  gastrica  is  that  they  can  not  be  grouped  with 
the  forms  of  psychoses  or  neuroses  in  which  anatomical  lesions  of 
the  central  nervous  system  can  not  be  demonstrated  with  the  meth- 
ods thus  far  at  our  disposal. 

Although  we  can  not  positively  say  that  real  pathological  ana- 
tomical changes  are  lacking,  yet  we  can  usually  exclude  great  altera- 
tions in  the  chemical  functions,  even  though  this  is  not  always  justi- 
fiable. 

Leube  ^  divides  the  cases  of  nervous  dyspepsia  into  those  with 
normal,  excessive,  and  lessened  secretion  of  HCl.  I  do  not  wish  to 
argue  vrith  this  distinguished  clinician  who  was  the  first  to  direct 
attention  to  nervous  dyspepsia,  yet  I  would  state  that  in  so  doing 

*  Richter.  Uebev  nervose  Dyspepsie  und  nervose  Enteropathie.  Berliner  klin. 
Wochenschr.,  1882,  No,  13. 

f  Leyden.  Ueber  periodisches  Erbrechen  (gastrische  Krisen).  Zeitschr.  fiir 
klin.  Med.,  Bd.  iv,  1882. 

X  Leube.  Spec.  Diagnose  der  innerer  Krankheiten.  3te  Auflage,  1891,  pp.  265 
et  seq. 

35 


536  DISEASES  OF  THE  STOMACH. 

he  has  become  untrue  to  his  original  definition,  the  chief  feature  of 
which  was  this  very  absence  of  marked  changes  in  the  chemical 
functions  of  the  stomach.  It  has  therefore  seemed  proper  to  me  to 
separate  and  classify  as  independent  conditions  or  neuroses  some  of 
the  cases  which  Leube  includes  under  the  head  of  "  nervous  dys- 
pepsia." 

In  many  cases  an  indigestion  of  short  or  long  duration,  a  mild 
catarrh,  frequently  recurring  hypersemia,  and  the  like,  have  surely 
been  the  primary  cause  of  the  manifestation  of  the  nervous  symp- 
toms in  the  digestive  organs.  Indeed,  such  injurious  conditions  may 
recur  during  the  course  of  the  disease,  and  may  produce  a  tempo- 
rary aggravation  thereof,  because  they  are  added  to  the  factors  already 
existing.  But  if  we  encounter  leucorrhoea  or  dyspeptic  disturbances 
during  chlorosis,  or  if  we  see  retinal  changes  in  Bright's  disease,  we 
will  never  consider  these  conditions  as  anything  but  symptoms  of  a 
general  malady. 

In  my  opinion  there  can  be  no  doubt  that  these  dyspeptic  con- 
ditions are  the  manifestations  of  general  neurasthenia.  In  rare 
cases  this  may  be  developed  only  in  the  nerves  of  the  stomach  and 
intestines,  and  apparently  the  lesion  is  in  one  of  the  peripheral 
nerves.  In  the  vast  majority  of  cases  these  local  symptoms  are  com- 
bined with  others  of  a  nervous  nature,  and  among  which  they  oc- 
cupy a  pre-eminent  place. 

For  the  diagnosis  of  dyspeptic  neurasthenia  there  are  no  single 
characteristic  symptoms.  Therefore  it  can  not  be  made  simply  from 
the  results  of  one  examination,  and  the  complaints  of  the  patient  at 
that  time  ;  the  more  so  since  not  infrequently  organic  lesions  may 
go  hand  in  hand  with  neurasthenic  conditions.  A  correct  diagnosis 
is  possible  only  after  a  prolonged  observation  of  the  course  of  the 
disease,  discovery  of  the  causal  factors,  the  failure  of  all  measures 
directed  toward  suspected  organic  diseases  of  the  stomach  and  intes- 
tines, and  a  proper  estimation  of  all  the  signs  of  neurasthenia  which 
may  be  present.  As  Burkart  has  rightly  suggested,  particularly 
great  value  is  to  be  laid  upon  the  peculiar  character  of  the  indi- 
vidual symptoms,  on  account  of  their  mutual  relations  to  one  an- 
other, and  their  changeable  occurrence. 

This  is  also  true  of  R.  Burkart's  pcinful  points  in  the  abdomen. 


NEURASTHENIA  GASTRICA.  537 

wliich  have  already  been  described  [page  494],  There  is  nothing 
about  them  which  is  characteristic  of  gastric  neurasthenia.  They 
can  not  be  mistaken  for  gastralgias,  enteralgias,  and  the  painful 
sensations  in  the  abdominal  parietes ;  the  latter  not  infrequently 
radiate  from  the  infrasternal  depression  as  lancinating  pains,  and 
might  well  be  called  epigastralgic,  as  proposed  by  Briquet. 

I  would  also  like  to  direct  attention  to  the  following  :  First,  the 
gastralgic  pains  are,  as  a  rule,  diffuse,  and  do  not  have  that  distinct, 
sharply  localized  character  observed  in  ulcer  or  cancer  of  the  stom- 
ach. They  are  also  much  less  dependent  upon  taking  food,  although 
this  relation  is  also  very  variable  in  carcinoma. 

Secondly,  vomiting  occurs  very  rarely  in  gastric  neurasthenia. 
When  it  does  occur,  it  consists  of  mucus  mixed  with  bile  and  rem- 
nants of  food  in  various  stages  of  digestion,  but  never  of  bloody  or 
decomposed  masses.  It  is  distinguished  from  hysterical  vomiting 
by  the  ease  and  regularity  with  which  the  latter  usually  occurs. 
The  taste  of  the  vomit  is  not  offensive,  but  bitter.  I  am  inclined  to 
agree  with  Liebreich,  that  the  taste  in  these  cases  is  due  not  to  bile 
but  to  peptones,  which  are  well  known  to  have  a  very  sharp  and  bit- 
ter taste.  In  belching,  with  the  regurgitation  of  acrid  masses,  this 
is  undoubtedly  the  case. 

Thirdly,  the  stools — of  which  I  have  examined  a  large  number 
in  the  course  of  time — ^have  the  usual  changeable  character  described 
by  Lambl,  and  later  by  Kothnagel.*  In  no  case  did  I  find  an  un- 
usual quantity  of  undigested  remnants  of  food  or  mucus,  or  even  of 
blood.  The  form  of  the  faeces  is  also  very  variable.  I  have  ob- 
served nothing  of  a  typical  character.  Of  not  infrequent  occurrence 
are,  however,  the  membranous,  flattened,  vermicelli-hke  or  tubular 
masses,  sometimes  grayish  white,  at  others  brownish  in  color,  wliich 
at  times  are  passed  in  enormous  quantities  in  the  stools.  This  con- 
dition has  incorrectly,  I  believe,  been  described  as  membranous  en- 
teritis and  cohtis,  because  these  products  have  nothing  to  do  with 
an  inflammatory  condition  of  the  intestinal  mucosa.  On  the  con- 
trary, as  has  also  been  shown  by  Kitagawa,-f-  they  consist  of  numer- 

*  Nothnagel.  Beitrage  zur  Physiologie  und  Pathologie  des  Darmes,  Ber- 
lin, 1884. 

f  Kitagawa.     Beitrage  zur  Physiologie  und  Pathologie  des  Darmes.     Berlin, 


538  DISEASES  OF  THE  STOMACH. 

0U8  broken-down  cells  and  brownish  fragments  and  detritus,  which 
are  imbedded  in  a  fibrinous  and  somewhat  tenacious  basement-sub- 
stance, in  which  remnants  of  organized  tissue  can  never  be  detected, 
but  which,  on  the  contrary,  on  adding  acetic  acid  give  the  charac- 
teristic reaction  of  mucin.  In  all  probability  they  are  formed  from 
an  overproduction  of  intestinal  mucus. 

Concerning  the  differential  diagnosis^  I  shall  not  speak  of  the 
neoplasms,  ulcers,  strictures,  etc.,  which  may  be  recognized  by  pal- 
pation, inspection,  or  by  very  characteristic  symptoms,  but  instead  I 
shall  state  that  the  initial  stage  of  a  neoplasm  in  the  stomach  may 
simulate  a  neurosis,  and,  on  the  other  hand,  that  a  chronic,  distinc- 
tive process  like  phthisis  or  carcinoma  may  be  diagnosticated  where 
really  only  a  neurosis  exists.  It  may  happen  that  a  long  time  may 
be  required  before  a  positive  diagnosis  can  be  made. 

Indeed,  we  should  endeavor  to  realize  the  fact  that  in  very  many 
cases  it  is  impossible  to  recognize  a  neurosis  zX  the  first  glance,  and 
that  only  prolonged  observation,  a  very  carefully  taken  history,  and 
a  consideration  of  the  general  condition  will  strengthen  the  diag- 
nosis and  exclude  other  conditions.  Intercostal  neuralgia  has  also 
given  rise  to  errors ;  and  although  I  have  never  met  such  a  case, 
which  must  necessarily  be  rare^  it  should  nevertheless  always  be 
borne  in  mind. 

Where  the  diagnosis  is  doubtful  concerning  the  possibility  of  a 
gastric  ulcer,  there  is  an  additional  factor  to  which  I  always  pay 
attention — ^i.  e.,  for  the  reasons  given  on  page  422,  I  am  afraid  to 
introduce  the  stomach  tube,  and  I  thus  avoid  the  risk  of  causing  a 
perforation  for  the  sake  of  information  which  may  be  doubtful ; 
therefore  it  seems  much  more  important  to  me  to  treat  the  sus- 
pected ulcer  with  appropriate  remedies,  and  let  the  diagnosis  depend 
upon  the  results  of  such  a  course  of  treatment. 

The  prognosis  is  as  uncertain  here  as  it  is  in  all  neurasthenic 
affections.  Some  cases  are  quite  rapidly  cured  by  suitable  treat- 
ment, and  may  remain  well  permanently  or  temporarily  ;  but  there 
are  others  which  for  years  resist  all  the  efforts  of  rational  thera- 
peutics.    The  course  which  an  individual  case  will  pursue  can  not 

1884,  [This  subject  has  been  carefully  studied  by  Akerlund.  Boas's  Archiv,  1896, 
Bd.  i,  p.  396.— Ed.] 


GASTROPTOSIS.  539 

be  predicted  in  advance.  It  is  natural  to  suppose  that  the  chances 
are  best  where  the  symptoms  have  been  mild,  and  vice  versa ;  but 
on  this  very  point  I  Have  repeatedly  erred.  Apparently  very  severe 
cases  are  cured  in  a  relatively  short  space  of  time,  while  seemingly 
simple  ones  persist  for  years.  In  general,  only  this  much  can  be 
premised,  that  at  best  the  trouble  is  one  of  long  duration,  lasting 
for  months  at  least,  and  that  the  external  appearance  of  the  patient 
affords  no  clew  to  the  severity  of  the  neurasthenic  symptoms.  I 
have  frequently  treated  young  men  who  were  the  picture  of  health, 
and  whose  complaints  were  therefore  ridiculed.  There  are  other 
cases  in  which  the  patients  decline  very  much,  emaciate,  and  become 
so  miserable  that  some  English  wi'iters  have  even  described  extreme 
conditions  of  weakness,  with  terminal  oedema,  fever,  and  death. 

Possibly  this  is  the  best  place  to  discuss  a  group  of  symptoms 
which,  unlike  nervous  dyspepsia,  is  due  to  a  distinct  pathological 
cause ;  I  refer  to  the  condition  described  by  Glenard  as  euteroptosis 
and  gastroptosis  [see  p.  89]. 

In  this  condition,  which  I  have  studied  very  carefully,*  there  is 
a  relaxation  of  the  ligaments  of  the  abdominal  viscera,  especially 
of  the  stomach,  intestines,  and  the  large  abdominal  glands,  which 
allows  these  organs  to  descend,  and  thus  produces  changes  in  the 
circulation  with  their  consequences.  The  clinical  picture  is  well 
known  to  all ;  it  consists  of  distinct  dyspeptic  disturbances  combined 
with  nervous  symptoms  which  may  arise  sympathetically  in  the  en- 
tire organism. 

The  digestive  symptoms  are  disturbances  of  appetite,  anorexia  or 
false  sensations  of  hunger,  a  sense  of  fulness  in  the  epigastrium, 
belching,  acid  taste  and  dryness  of  the  mouth,  burning  or  shooting 
pains  in  the  epigastrium  after  eating.  Constipation  alternating  with 
so-called  false  diarrhoea  is  common,  scybalse,  which  are  almost  as 
hard  as  stone  and  frequently  coated  with  mucus,  being  passed  after 
severe  straining  and  after  taking  strong  purgatives  or  enemata ; 
large  fragments  of  membrane,  as  in  membranous  enteritis,  are  often 
observed.     At  the  same  time  the  abdomen,  especially  its  lower  por- 

*  Ewald.    Ueber  Enteroptose  und  Wanderniere.     Berl.  klin.  Woehenschr.,  1890, 
No.  13.     A  full  bibliography  is  given  in  this  paper. 


540  DISEASES  OP  THE  STOMACH. 

tion,  is  somewhat  distended ;  dragging  pains  and  abundant  flatus  are 
complained  of. 

The  general  nervous  symptoms  include  general  weakness,  change- 
able and  depressed  moods,  headaches  and  fulness  of  the  head,  ver- 
tigo, heaviness  of  the  limbs,  the  hands  and  feet  feel  cold,  palpitation, 
disturbance  of  sleep  and  frequent  pains  in  the  back  which  are  re- 
ferred to  definite  localities.  Further  general  symptoms  are  emacia- 
tion, rapid  loss  of  weight,  pallor,  falling  out  of  hair,  eczema,  and  the 
like.  The  loss  of  weight  may  at  times  be  so  marked  that  the  patient 
or  his  friends  fear  cancer  or  malignant  diseases.  [On  the  other 
hand,  there  are  many  cases  of  gastroptosis  which  give  rise  to  no 
clinical  symptoms.  When  symptoms  are  present,  they  need  not 
always  be  constant  but  may  occur  in  paroxysms.  Chlorosis  is  said 
by  Meinert  to  be  a  constant  symptom  of  this  condition ;  indeed,  he 
maintains  that  gastroptosis  is  the  chief  cause  of  chlorosis  in  women 
(see  p.  571).] 

On  examination  we  find  a  more  or  less  marked  mobility  or  dis- 
placement of  the  kidneys,  sometimes  of  the  liver,  and  downward 
displacement  of  the  stomach,  i.  e.,  gastroptosis,  a  symptom  which  may 
readily  be  demonstrated.  If  the  stomach  be  distended  by  means  of 
the  methods  described  on  page  85,  it  will  project  on  the  anterior 
wall  like  an  air  cushion  so  that  the  upper  border  may  be  seen  in  the 
middle  line  a  little  above  the  umbilicus,  the  lower  border  being  be- 
tween the  latter  and  the  symphysis.  Besides  this  there  is  also  usu- 
ally a  dislocation  of  the  liver  and  transverse  colon,  while  the  small 
intestines  sink  deeply  into  the  pelvis. 

Arguing  from  a  theory  which  need  not  now  be  discussed,  because 
it  has  no  sufiicient  pathological  basis  and  because  it  is  not  verified 
by  clinical  observations,  Glenard  *  assumed  that  these  various  dis- 
placements were  caused  by  a  bending  of  the  transverse  colon  near 
the  ligamentum  colico-hepaticum.  As  the  result  of  this  the  colon, 
lying  to  the  other  [left]  side  of  this  place,  collapses  and  becomes  con- 
tracted into  a  sausagelike  mass  which  can  be  felt  extending  from 
the  left  to  the  right.     Glenard  lays  great  stress  on  this  symptom, 

*  Grlenard.  De  I'Enteroptose.  Paris,  1885,  and  numerous  articles  and  theses 
by  Trastour,  Fereol,  Cuilleret,  Cheron,  Raoult,  Blanc-Champagnoe,  Ott,  Meinert, 
Ctilapowski,  etc. 


GASTROPTOSIS. 


541 


which  he  calls  the  corde  oblique.  As  the  result  of  this  the  mesen- 
teries become  relaxed  so  that  the  small  intestines  sink  into  the  pelvis 
and  drag  down  the  stomach,  kidneys,  and  sometimes  even  the  liver 
itself.  However,  my  own  experience  is  that  in  the  majority  of  cases 
the  contracted  colon  can  not  be  palpated ;  on  the  contrary,  what  is 


Fig.  46. — Sketch  of  positions  of  abdominal  viscera  in  splanchnoptosis,  a,  liver ;  c,  stomach  ; 
£?,  pancreas ;  e,  e,  duodenum  ;  _/,  transverse  colon  ;  ^,  descending  colon  ;  A,  small  intes- 
tines ;  w,  umbilicus. 

felt  is  the  pancreas,  the  horizontal  portion  of  which,  as  is  shown  in 

the  accompanying  sketch  (Fig.  46),  can  be  felt  above  the  lesser 

curvature  because  it  is  now  no  longer  covered  by  the  stomach,  as 

occurs  under  normal  conditions. 

1  shall  cite  the  following  instructive  case  to  demonstrate  these 

relations.     It,  together  with  the  sketch  (Fig.  46),  is  taken  from  a 

dissertation  by  Poltowicz,*  of  Prof.  Roux's  clinic  in  Lausanne.    The 

sketch  is  of  especial  value  because  it  is  drawn  from  the  condition 

found  at  a  laparotomy. 

The  patient  was  a  fifty-year-old  woman  who  gradually  became  ill  with 
dyspeptic  symptoms  accompanied  by  vomiting  (at  times  it  was  black  and 

*  Poltowicz.     Contribution  a  I'etude  de  la  maladie  de  Grienard,  etc.     Inaug. 
Diss.    Lausanne,  1893. 


542  DISEASES  OF  THE  STOMACH. 

once  consisted  of  two  tablespoonfuls  of  blood),  obstinate  constipation,  and 
marked  emaciation.  Dislocation  and  dilatation  of  the  stomach  could  be 
made  out,  but  no  tumor  was  palpable  ;  but  as  a  neoplasm  was  suspected, 
after  a  time  an  exploratory  laparotomy  was  performed.  The  operation 
must  have  been  very  "  thorough  "  as  the  following  report  will  show :  "  The 
liver  is  completely  dislocated  and  is  somewhat  rotated  on  its  axis,  so  that 
the  gall  bladder  lies  in  the  axillary  line.  The  right  kidney  lies  below  the 
liver  in  its  normal  situation.  The  stomach  is  slightly  filled,  has  thin  walls, 
is  but  little  distended  in  the  pyloric  region,  but  is  enormously  dilated  at  the 
fundus,  which  has  sunk  down  into  the  pelvis.  The  same  is  true  of  the 
duodenum.  The  omentum  and  small  intestines  are  in  the  pelvis.  The  pan- 
creas is  about  the  lesser  curvature.  Nothing  but  the  mesentery  and  ab- 
dominal aorta  lie  on  the  lumbar  vertebrae.  The  transverse  and  descend- 
ing colon  are  strongly  contracted,'  the  former  being  in  the  form  of  a  cord 
which  runs  across  the  abdomen  below  the  umbilicus." 

In  spite  of  this  somewhat  extensive  laparotomy,  as  must  be  confessed, 
the  patient  was  discharged  "  cured  "  at  the  end  of  five  weeks,  and  was  re- 
ported to  be  feeling  well  and  having  a  good  appetite. 

It  is  inconceivable  how  simple  manipulation,  etc.,  of  the  abdom- 
inal viscera  should  cure  such  marked  symptoms,  a  point  which 
the  writer  does  not  discuss.  The  description,  however,  which  he 
gives  of  the  situation  of  the  viscera  is  an  excellent  picture  of 
splanchnoptosis.  I  myself  have  observed  a  similar  very  typical  case 
in  a  corpse  in  which  the  kidneys  were  also  movable  and  in  which 
absolutely  nothing  in  the  way  of  old  inflammatory  adhesions  could 
be  discovered  ;  I  shall  refrain  from  describing  it,  as  the  above  case 
will  suffice.  Meinert  *  has  photographed  a  number  of  typical  cases 
of  gastroptosis ;  Krez,f  of  Leube's  clinic,  has  also  published  a  typical 
case  with  a  detailed  account  of  the  autopsy ;  the  interesting  feature 
of  the  case  was  that  the  pancreas  was  palpated  during  life,  as  de- 
scribed above,  and  the  finding  was  corroborated  at  the  autopsy. 

The  fact  that  such  displacements  of  the  intestines  may  possibly 
occur  even  during  fcetal  life,  or  may  be  predisposed  to  during  child- 
hood, can  not  be  denied ;  X  yet  in  this  connection  we  must  distin- 
guish two  classes  of  cases  : 

*  Meinert.  Dresdener  Jahresbiicher,  1891-'93.  [A  large  number  of  photo- 
graphs of  cases  of  gastroptosis  will  be  found  in  Meinert's  monograph.  Volkmann's 
klinische  Vortrage,  Nos.  115  and  116,  January,  1895. — Ed.] 

f  L.  Krez.  Zur  Frage  der  Enteroptose.  Munch,  med.  Wochenschr.,  1892., 
No.  34. 

X  [Thus,  according  to  Meinert,  a  long  and  narrow  thorax  predisposes  phthisical 
patients  to  splanchnoptosis.  Rickets  also  predisposes  even  young  children.  See 
Figs.  10-14  in  Meinert,  loc.  cit. — Eu.] 


GASTROPTOSIS.  543 

1.  This  group  includes  those  cases  in  which  the  displacement  of 
the  viscera  is  the  demonstrable  result  of  antecedent  inflammatory 
processes,  especially  such  as  proceed  from  the  genital  organs  in 
women.  Such  conditions  have  formerly  been  repeatedly  described, 
and  Yirchow,  in  discussing  my  paper  on  enteroptosis,  stated  that  these 
changes  were  known  long  ago.  It  was  equally  well  known  that 
such  conditions  could  be  followed  by  the  above-mentioned  sub- 
jective symptoms  to  a  greater  or  less  degree.  But  the  disorder  does 
not  consist  so  much  in  an  exclusive  downward  displacement  of  these 
viscera,  as  it  does  in  the  distortion  and  displacements  which  may 
at  times  also  lead  to  the  sinking  down  of  the  organs. 

2.  However,  splanchnoptosis  as  regarded  by  Glenard  and  myself 
has  nothing  to  do  with  these  cases ;  it  includes  a  group  of  cases 
which  are  entirely  independent.  In  the  dislocations  after  old  in- 
flammatory processes,  only  isolated  coils  of  intestines  or  organs  are 
involved,  but  in  Glenard's  disease,  as  splanchnoptosis  is  sometimes 
called,  there  is  a  general  descent  of  all  the  abdominal  organs  above 
mentioned,  and  in  the  histories  of  these  cases  there  is  absolutely  no 
reference  to  any  such  antecedent  inflammation.  If  any  etiological 
factors  can  be  discovered  at  all,  they  will  be  severe  bodily  exertion, 
concussion  of  the  abdominal  viscera,  protracted  and  frequent  labors, 
tight  lacing,  and,  finally,  antecedent  prolonged  dyspepsias  which 
have  occasioned  the  enteroptosis  as  the  result  of  the  change  in  the 
pressure  and  tension.  Thus  enteroptosis  may  cause  dyspepsia  or 
vice  versa. 

Enteroptosis  occurs  far  more  frequently  in  women  than  in  men. 
In  Glenard's  404  cases,  306  were  women.  [Tight  lacing  and  preg- 
nancy are  the  chief  causes  of  this  great  difference  in  the  two  sexes.] 

I  would  not  be  understood  as  having  stated  that  only  true  enter- 
optosis can  lead  to  the  above-mentioned  symptoms.  For  the  sec- 
ondary displacements  of  the  abdominal  viscera,  and  especially  of  the 
stomach  and  intestines,  may  give  rise  to  exactly  similar  clinical  pic- 
tures, in  which  it  is  natural  that  the  chief  place  should  be  occupied 
by  the  primary  causal  factor. 

Concerning  the  relation  between  floating  kidney  and  dilatation 
of  the  stomach,  I  would  refer  to  what  has  already  been  said  on 
page  275. 


544  DISEASES  OP  THE  STOMACH. 

Here  it  will  suffice  to  say  that  the  existence  of  gastroptosis  and 
enteroptosis  has  now  been  corroborated  by  many  writers,*  and  that 
the  simple  method  of  distending  the  stomach  and  intestines,  com- 
bined with  palpation  of  the  abdominal  organs,  have  enabled  us  to 
isolate  from  the  great  mass  of  cases  of  nervous  dyspepsia  a  group 
of  cases  in  which  palpable  anatomical  changes  which  can  be  demon- 
strated during  life  are  the  causal  factors.  In  discussing  the  treat- 
ment, I  shall  be  able  to  show  that  we  are  now  able  to  treat  these 
conditions  better  than  formerly. 

[On  the  other  hand,  many  cases  of  gastroptosis  exist  which  give 
absolutely  no  symptoms  at  all ;  but  if,  however,  for  some  reason  or 
another,  the  general  health  is  impaired,  the  compensation  which  has 
been  established  will  be  disturbed  and  the  examination  will  then  re- 
veal the  displacement  of  the  viscera.] 

TV.  Keflex  Gasteic  Leukoses  fkom  other  Organs. 

Under  this  heading  I  include  palpable  changes  in  organs  other 
than  the  stomach,  whose  effects  are  observed  in  the  gastric  nerves ; 
in  other  words,  those  morbid  manifestations  to  which,  like  all  other 
reflex  conditions,  the  axiom  Ablata  causa  cessit  effectus  has  a  spe- 
cial significance.  Too  frequently  is  the  cause  of  the  cases  sought, 
not  in  the  real  primary  area,  but  incorrectly  in  the  place  second- 
arily involved ;  therefore,  a  brief  rSsunie  of  the  reflex  symptoms 
known  to  us  may  serve  to  remind  you  what  organs  and  morbid 
processes  are  to  be  especially  considered. 

The  reflexes  manifest  themselves  as  (1)  mild  disturbances  of 
digestion ;  (2)  gastralgias ;  (3)  vomiting ;  the  latter  occurs  espe- 
cially in  acute  affections,  the  former  in  those  of  a  more  chronic  na- 
ture. But  just  as  these  three  types  may  very  frequently  be  inter- 
changeable, and  even  occur  in  combination,  so  may  chronic  proc- 
esses give  rise  to  the  symptoms  of  an  acute  gastric  disorder,  if  they 
exacerbate  suddenly  or  involve  specially  predisposed  nervous  plex- 

*  Ott.  LTeber  die  Glenard'sche  Krankheit.  Prager  med.  Wochenschr.,  1892,  No. 
46.  and  the  works  already  quoted.  [This  subject  is  fully  discussed  in  the  recent 
monographs  of  Meinert,  op.  cit. ;  Kelling,  Volkmann's  klin.  Vortrage,  No.  144,  Feb- 
ruary, 1896:  Fleiner,  Ueber  die  Beziehung  der  Form  und  Lageanderung  des 
Magens.     Miinch.  med.  Wochenschr.,  1895,  Nos.  42-45.— Ed.] 


REFLEX  GASTRIC   NEUROSES.  545 

uses,  etc.,  in  their  course.  This  is  well  shown,  for  example,  in  the 
crises  of  locomotor  ataxia. 

The  fact  has  been  repeatedly  mentioned  that  the  stomach  is  the 
center  of  a  nervous  plexus  whose  branches  have  very  wide  connec- 
tions, and  directly  or  indirectly  involve  nearly  every  organ  in  the 
body ;  hence,  an  irritation  which  is  manifested  at  any  point  in  this 
plexus  will  reach  the  stomach,  just  as  in  any  peripheral  end-appa- 
ratus. Of  especial  importance  are  the  reflexes  from  the  central 
nervous  system,  the  great  glandular  organs  in  the  abdomen,  the  in- 
testines, genital  tract,  and,  finally,  the  heart  and  lungs. 

The  cerebral  disorders — meningitis,  haemorrhages,  abscesses,  tu- 
mors— are  usually  accompanied  by  vomiting  of  a  transitory  or  more 
permanent  character,  and  frequently  by  hypersecretion  of  the  gas- 
tric juice,  as  was  already  known  to  Andral.*  This  abundant  secre- 
tion of  gastric  juice  during  life  will  therefore  explain  the  rapidity 
with  which  post-mortem  softening  of  the  stomach  may  take  place 
in  these  cases.  Yomiting  usually  occurs  during  the  course  of  the 
disease,  or  it  may  usher  it  in  and  thus  cause  great  misconceptions, 
as  is  well  known  in  meningeal  inflammation,  especially  of  children, 
and  in  tumors.  Therefore,  every  case  of  long  standing,  or  even  un- 
yielding vomiting,  must  be  considered  from  this  standpoint.  The 
vomiting  of  seasickness,  migraine,  and  the  beginning  of  psychical 
affections,  may  also  be  included  in  this  variety  of  reflex  vomituig. 
Of  the  latter  occurrence  I  have  two  examples  in  which,  appar- 
ently from  a  gastric  catarrh,  very  obstinate  vomiting  was  developed, 
which,  after  having  lasted  several  weeks,  was  followed  by  a  psycho- 
sis. Lesions  in  the  cervical  and  dorsal  portions  of  the  spinal 
cord  cause  gastralgia,  sometimes  with  vomiting,  as  soon  as  the 
centers  or  nerve-roots  concerned  are  involved.  Such  "gastric 
crises"  occur  not  alone  in  the  gray  degeneration  of  the  posterior 
columns  (tabes),  but  also  in  insular  lesions  of  disseminated  sclerosis. 
Vomiting  is  also  of  frequent  occurrence  in  abscesses  and  calculi  in 
the  liver  and  kidneys,  especially  when  they  pass  into  the  excretory 
ducts  and  thus  irritate  their  sensory  nerves. 

I  will  recall  the  vomiting  of  pregnancy  not  alone  to  indicate  a 

*  Quoted  by  Budd,  loc.  cit. 


546  DISEASES  OP  THE  STOMACH. 

very  common  reflex  upon  the  stomacli,  but  also  a  not  infrequent 
source  of  diagnostic  doubts  and  errors.  How  frequently  has  ap- 
parently serious  vomiting,  whidi  simulated  some  grave  disorder  of 
the  stomach,  simply  proved  to  be  the  first  manifestation  of  a  preg- 
nancy !  It  occurs  in  the  early  part  of  gestation,  while  the  uterus  is 
still  in  the  pelvis,  since  this  variety  of  vomiting  is  due  to  the  press- 
ure of  the  enlarged  womb  upon  the  sympathetic  nerves.  The  dis- 
order may  reach  such  a  degree  that  all  remedies  are  useless,  if  the 
uterus  is  unusually  large  or  is  misshapen,  or  if  its  muscular  fibers 
are  inflamed,  or  if  it  is  misplaced.  But  acute  injuries  or  maltreat- 
ment of  this  organ  may  also  cause  vomiting — e.  g.,  snaring  a  polyp 
at  the  fundus  uteri  preparatory  to  its  removal.  Dr.  Daumann  had 
such  a  case  in  which  pain  in  vomiting  set  in  every  time  the  loop  was 
tightened,  while  the  latter  ceased  as  soon  as  the  ligature  was  loos- 
ened. The  same  thing  has  been  observed  in  operations  on  the  blad- 
der, urethra,  etc. 

Chronic  disorders  of  the  female  as  well  as  of  the  male  sexual 
organs  may  be  followed  by  chronic  dyspeptic  conditions.  I  would 
here  remind  you  that  the  normal  process  of  menstruation  causes 
retardation  of  gastric  digestion,  or  even  complete  absence  of  free 
hydrochloric  acid  in  the  stomach  contents,  as  was  first  demonstrated 
by  Kretschy,*  and  later  confirmed  by  neischer,f  and  Boas  and 
myself.  :|:  How  much  greater  reflexes  will  be  referred  to  the  stom- 
ach and  intestines  by  amenorrhoea  and  dysmenorrhoea,  the  climac- 
teric period  and  chronic  disorders  of  uterus  which  are  associated 
with  an  irritability,  or  even  with  a  direct  excitation  of  its  nerves ! 
Hence  we  can  understand  why  Kisch  *  found  "  dyspepsia  uterina  " 
most  frequently  in  retroflexion  of  the  enlarged  uterus,  then  in  mal- 
positions in  general,  myomata,  pelvic  exudations  with  traction  on 
the  uterus  and  its  adnexa,  follicular  or  carcinomatous  ulcers  of  the 
cervix,  and  ovarian  tumors ;  but  it  was  absent  in  simple  and  mild 

*  F.  Kretsehy.  Beobachtungen  und  Versuche  an  einer  Magenfistelkranken. 
Deutsehes  Archiv  fiir  klin.  Med.,  Bd.  xviii,  S.  257. 

•j-  E.  Fleischer.  Ueber  die  Verdauungsvorgange  im  Magen  unter  verschiedenen 
Einfliissen.     Berl.  klin.  Wochenschr.,  1882,  No.  7. 

X  Ewald  und  Boas.  Zur  Physiologic  und  Pathologie  der  Verdauung.  Vir« 
chow's  Archiv,  Bd.  civ. 

*  H.  Kisch.     Dyspepsia  uterina.    Berl.  klin.  Wochenschr.,  1883,  No.  18. 


REFLEX  GASTRIC   NEUROSES.  547 

endometritis,  chronic  catarrhs,  and  small  perimetric  and  parametric 
exudations.  Such  dyspeptic  conditions  which  may  have  persisted 
for  years  have  been  cured  in  a  surprisingly  short  time  by  appro- 
priate local  treatment. 

I  liave  recently  observed  a  peculiar  and  rare  example  of  a  reflex  of  this 
kind  which  first  involved  the  salivary  glands  and  indirectly  the  stomach — 
i.  e.,  sialorrhoea  with  dyspepsia  resulting  therefrom.  An  unmarried  lady, 
forty-one  years  of  age,  was  said  by  her  physician  to  have  suffered  for  two 
and  a  half  montlis  fi'om  loss  of  appetite,  bitter  taste  in  the  moiith,  consti- 
pation, feeling  of  oppression  over  the  stomach,  and  for  several  weeks  very 
severe  salivation.  She  was  much  emaciated,  felt  very  weak,  and  had  the 
greatest  repugnance  toward  exerting  herself,  although  she  was  formerly 
very  active.  She  lived  upon  her  estate,  and  had  already  taken  Carlsbad 
water,  condurango,  nitrate  of  silver,  and  small  doses  of  quinine  ;  cold  rub- 
bings and  suitable  diet  had  also  been  tried,  but  all  without  success,  On 
the  patient's  admission  to  the  sanitarium  the  amount  of  saliva  secreted 
daily  was  found  to  be  about  two  litres  [4^  pints] ;  this  was  examined  in  Prof. 
Kossel's  laboratory  and  found  normal.  No  great  changes  discovered  in 
the  gastric  chemical  functions ;  acidity  48.  No  other  anomalies  found ; 
the  mouth  was  free  from  any  special  disease.  Every  kind  of  poisoning  by 
the  coating  of  mirrors,  mouth  washes,  hair  dyes,  and  the  like,  was  ex- 
cluded. After  a  fortnight's  trial  of  pills  of  atropine,  and  hyjDodermic  in- 
jections of  morphine  and  atropine,  with  only  temporary  effect  on  the 
symptoms,  I  discovered  a  retroflexion  of  the  uterus.  "With  the  introduc- 
tion of  a  pessary  the  obstinate  ptyalism  and  the  dyspeptic  condition  very 
soon  disappeared. 

Keflex  gastric  neuroses  from  the  generative  organs  occur  in  men 
as  well  as  in  women,  a  relation  which  occurs  much  more  commonly 
than  is  usually  supposed.  I  have  already  referred  to  the  effects  of 
sexual  errors  (onanism,  sexual  perversion,  and  excesses).  At  present 
I  refer  to  local  affections,  such  as  chronic  urethritis,  urethral  stric- 
tures, spermatorrhoea,  pollutions,  etc.,  with  reflex  gastric  neuroses. 
These  include  any  of  the  conditions  already  described,  i.  e.,  gastral- 
gia,  vomiting,  eructation,  cramps,  bulimia,  gastrosucchorea,  etc.  ;  but 
far  more  frequent  than  any  of  these  is  nervous  dyspepsia.  In  these 
cases  the  relation  between  the  genital  lesion  and  the  gastric  symp- 
toms is  established  by  the  fact  that  after  the  treatment  and  cure  of 
the  former,  the  latter  often — but,  alas !  not  always — disappear.  In 
the  course  of  months  I  have  seen  quite  a  number  of  these  cases,  but, 
as  I  have  already  hinted,  the  relief  of  the  gastric  trouble  by  no 
means  always  follows  the  cure  of  the  local  disease,  as  might  easily 


548  DISEASES  OP  THE  STOMACH. 

be  inferred  from  the  excellent  monograpli  of  Peyer ;  *  on  the  con- 
trary, the  gastric  neurosis  may  persist  long  after  the  disappearance 
of  the  local  disease. 

In  conclusion,  I  must  mention  the  reflexes  from  the  intestines, 
such  as  are  caused  by  worms,  enteroliths,  and  neoplasms  in  and 
about  the  gut.  The  parasites,  especially,  play  an  important  part 
here.  I  shall  not  go  into  details  about  the  serious  disturbances  of 
nutrition  which  may  be  caused  by  the  distoma  and  strongylus  varie- 
ties, neither  shall  I  speak  of  the  disease  of  tunnel  workmen  and 
brickburners.f  It  will  suffice  to  mention  the  ordinary  ascarides 
and  taenia,  and  recall  the  fact  that  many  a  long-standing  "  nervous 
dyspepsia  "  has  been  terminated  by  the  expulsion  of  a  tapeworm ! 

Treatment  of  the  !N^eueoses  or  the  Stomach. 

In  all  the  nervous  diseases  of  the  stomach  the  treatment  will 
depend  upon  the  question  whether  they  are  of  an  irritative  or  de- 
pressive nature. 

The  conditions  of  increased  irritability  must  be  separated  into 
those  in  which  the  hypersesthesia  is  local  and  those  which  are  cen- 
tral in  origin. 

For  local  hypersesthesia,  opium  and  its  derivatives — morphine, 
codeine,  and  narceine — have  been  invaluable  for  ages.  In  general, 
morphine  is  best  administered  in  watery  solution,  or  in  bitter-almond 
water,  since  it  is  not  dissolved  in  the  stomach  if  given  in  substance, 
or  has  little  or  no  action.  The  most  rapid  effects  may  be  obtained  by 
hypodermic  injection  in  loco  affecto;  I  usually  follow  the  English 
custom  of  adding  one  tenth  part  of  sulphate  of  atropine,  partly  to 
counteract  any  possible  nauseating  effects  of  the  morphine,  partly  to 
obtain  the  relaxing  effects  of  the  atropine.  This  is  an  excellent 
combination,  which  may  be  very  useful  in  patients  who  have  inva- 
riably had  nausea  and  vomiting  after  the  simple  morphine  solution. 
For  example,  in  bulimia,  Rosenbach  has  recommended  the  hypoder- 

*  A.  Peyer.  Ueber  MagenafEectionen  bei  mannlichen  Genitalleiden.  Volk- 
mann's  Samml.  klin.  Vortrage,  No.  356. 

f  [The  TunnelTcrankheit  or  Bergkachexie  is  a  form  of  anfernia  caused  by  the 
anchylostomum  duodenale.  It  has  also  been  called  Gothard  Tunnel  disease.  The 
same  parasite  is  the  cause  of  brickburner's  anaemia. — Ed.J 


TREATMENT  OF  GASTRIC  NEUROSES.  549 

mic  use  of  extract,  opii  which  has  been  dissolved  in  glycerin,  filtered 
and  diluted  with  water ;  but  I  have  had  no  occasion  to  use  it.  If 
the  general  sedative  effect  on  the  entire  nervous  system  is  desired, 
and  if  there  are  reasons  why  it  should  not  be  given  by  the  mouth, 
or  subcutaneously,  it  may  be  administered  in  suppositories  of  0'03 
to  0-05  [gr.  ^  to  f]  each,  or  O'l  to  0-15  [gr.  j|-  to  ij:^]  per  day.  The 
action  of  opium  and  morphine  may  be  assisted  by  hydrocyanic  acid, 
in  small  doses,  in  the  form  of  aqua  amygdalae  amarse.  Hydrochlo- 
rate  of  cocaine  may  be  unhesitatingly  given  internally,  in  doses  of 
0*05  to  0*1  gramme  [gr.  |-  to  jss.]  ;  yet  one  must  not  forget  that,  in 
some  individuals,  even  the  first  dose  may  be  followed  by  unpleasant 
symptoms  of  irritation — sleeplessness,  restlessness,  pulsation  of  the 
arteries,  and  oppression  and  pain  in  the  head.  For  prolonged  use 
and  where  the  symptoms  are  mild,  coca  wine  may  sometimes  be 
valuable.  As  an  antispasmodic  we  may  use  the  preparations  of 
belladonna,  either  pills  of  extract  of  belladonna  or  atropine,  or  the 
tincture. 

In  hysterial  hypersesthesige,  gastralgias,  vomiting,  and  even  in 
spasmodic  conditions,  I  have  been  very  well  satisfied  with  the  fol- 
lowing combination  of  the  remedies  mentioned  above : 

^  Morphinse  hydrochloratis ....      0*2  [gr.  iij] 

Cocainse  hydrochloratis 0'3-0-5     [gr.  ivss.-vijss.] 

Tincturse  belladonnse 5'0-10'0  [f  3  jj-ijss.] 

Aquae  amygdalae  amarae 25-0  [f  3  vjj] 

M.     Sig. :  Ten  to  fifteen  drops  every  hour. 

However  indispensable  morphine  may  be,  the  fact  of  its  subcu- 
taneous use  being  a  two-edged  sword  in  all  chronic  forms  of  disease 
is  well  known ;  and  it  is  just  in  neuroses  now  under  discussion  that 
both  physician  and  patient  should  always  keep  before  their  eyes  the 
terrible  dangers  of  the  morphine  habit. 

This  need  not  be  feared  with  chloral  in  3  to  5  per  cent  solution, 
sometimes  in  combination  with  cocaine,  to  be  taken  at  one  and  one 
half  to  two  hours'  intervals ;  it  has  a  good  sedative  action.  The 
feeblest  and  not  always  reliable  analgesics  are  the  preparations  of 
bismuth,  either  alone  or  in  combination  with  morphine  or  extract 
of  hyoscyamus  or — in  mild  cases,  and  especially  in  children — rhu- 
barb. 


550  DISEASES  OP  THE  STOMACH. 

^  Codein  phosphatis 0-2  [gr.  iij] 

Pulv.  rad.  ipecacuanhse 0*5  [gr.  vijss.] 

Bismutli  subnitratis 10"0  [  3  ijss.] 

ISTatrii  bicarbonatis, 

Sacchari  albi aa  15-0  [  2  ss] 

M.  Sig. :  One  teaspoonful  every  two  bours. 
Swallowing  small  pieces  of  cracked  ice  witb  three  to  five  drops 
of  chloroform,  may  be  recommended  for  rapidly  allaying  pain ;  the 
same  is  true  of  cbloroform-water,  wbicb  may  be  prepared  by  shak- 
ing water  with  an  excess  of  chloroform,  decanting  and  diluting  with 
half  the  quantity  of  an  aromatic  water ;  the  dose  is  a  tablespoonful 
at  intervals  during  the  day.  H.  Hirschberg  claims  that  cane  sugar 
in  large  doses  (40  to  50  grammes  [  |  j-|-  §  jf  ]  dissolved  in  water)  has 
temporary  analgesic  properties. 

Rosenthal,  Leube,  Yizioli,  and  Eosenbach  have  repeatedly  ob- 
served the  lessening  and  even  disappearance  of  gastralgias  by  the 
anodal  action  of  the  constant  current.  [Einhorn*  has  called  especial 
attention  to  the  value  of  intragastric  galvanization  in  gastralgia. 
This  method  has  also  given  me  excellent  results.  The  intragastric 
electrode  is  the  anode,  the  current  strength  being  about  8  to  15  mil- 
liamperes.  The  sittings  last  5  to  10  minutes,  and  are  daily  at  first, 
the  intervals  being  made  longer  as  the  pain  abates.]  A  sedative 
effect  is  also  claimed  for  the  continuous  use  of  the  "galvanic  chain  " 
(zinc  [negative]  pole  on  the  lumbar  portion  of  the  spinal  column,  the 
silver  [positive]  pole  upon  the  stomach). 

Surprising  results  may  sometimes  be  obtained  by  local  treatment 
with  the  internal  stomach  douche,  which  was  first  recommended  by 
Malbranc  f  (see  p.  99).  This  "  massage  of  the  stomach  "  seems  to 
exert  a  quieting  influence  on  the  hypersensitive  gastric  nerves,  just 
as  ordinary  massage  often  unexpectedly  relieves  painful  neuroses. 
Malbranc  has  formulated  Kussmaul's  experience  and  opinion  in  ex- 
planation of  the  beneficial  effects  of  the  stomach  douche  in  the  fol- 
lowing conclusions,  although  in  the  case  quoted  below  only  the  last 


*  Loc.  cit. 

f  M.  Malbranc.  Ueber  Behandlung  von  Gastralgien  mit  der  inneren  Magen- 
douche  nebst  Bemerknngen  iiber  die  Technik  der  Sondirung  des  Magens.  Berl. 
klin.  Wochenschr.,  1876,  S.  41. 


TREATMENT  OF   GASTRIC  NEUROSES.  551 

mentioned  are  concerned:  (1)  Removal  of  stagnant  remnants  of 
food  from  the  stomach ;  (2)  reHef  from  acid,  acrid  masses  (products 
of  decomposition)  and  mucus ;  (3)  the  quieting  effect  of  the  warm 
water  bath ;  (4)  stimulation  of  the  peristalsis  by  the  impact  of  the 
stream  of  water;  (5)  the  mildly  anaesthetic  as  well  as  the  stimulat- 
ing effects  on  the  muscular  fibers  of  the  stomach  from  the  carbonic- 
acid  gas ;  (6)  the  increase  in  the  peristalsis  of  the  intestines  by  the 
last  two  factors. 

As  an  example  of  the  beneficial  effects  of  the  douche  I  wish  to 
'describe  the  following  case  : 

A  married  woman,  thirty-six  years  old,  the  mother  of  one  child,  cam.e 
ten  days  before,  complaining  of  intense  gastralgia,  complete  loss  of  appe- 
tite, and  great  lassitude.  She  was  of  a  slight  build  and  her  appearance 
was  bad ;  her  eyes  especially  were  dull  and  languid,  as  they  are  after 
sleepless  nights.  Her  illness  began  five  months  previously  with  cramps 
in  the  stomach.  For  the  preceding  eight  weeks  the  attacks  had  occurred 
several  times  a  day ;  sometimes  they  were  almost  uninterrupted  and  were 
present  at  night  quite  independently  of  eating.  Nothing  abnormal  was 
found  in  the  stomach  and  abdomen ;  heart  and  lungs  were  normal. 
While  fasting,  about  30  c.  c.  [  |  j]  of  a  neutral  turbid  yellow  liquid,  which 
was  not  slimy,  were  expressed  from  the  stomach.  This  was  undoubtedly 
regurgitated  fluid  from  the  duodenum.  After  the  test  breakfast  the  acid- 
ity was  very  feeble,  with  only  a  trace  of  hydrochloric  acid.  She  had  a  large 
batch  of  prescriptions  of  various  narcotics  and  sedatives  which  she  had 
taken  without  any  benefit.  The  result  of  four  douches  was  that  only 
traces  of  the  attacks  occurred  during  the  daytime ;  the  appetite  returned, 
and  greater  quantities  of  food  were  consumed. 

Recently,  Rosenheim  has  also  given  several  examples  of  this 
kind  (see  page  7).  Cases  have  also  been  reported  by  Everett,* 
in  which  incessant  pains  were  relieved  by  lavage  of  the  stomach.  I 
myself  have  also  reported  similar  cases.  Undoubtedly,  as  in  elec- 
trical treatment,  a  large  part  of  the  good  effect  is  due  to  suggestion. 

A  similar  change  of  tone  in  the  nervous  apparatus  may  explain 
the  effect  of  the  introduction  of  the  stomach  tube  and  feeding 
through  it  in  severe  reflex  vomiting,  especially  in  the  vomiting  of 
pregnancy  ;  many  successful  examples  may  be  found  in  English 
Hterature.  On  the  other  hand,  I  must  agree  with  Oser,f  that 
washing  or  douching  the  stomach  has  no  permanent  effect  in  hy- 

*  Everett.    New  York  Meilical  Record,  1891,  No.  25. 
t  Oser.    Wiener  Kliaik,  1875,  S.  257. 


552  DISEASES   OF  THE  STOMACH. 

pochondriacs.  They  feel  well  as  long  as  the  treatment  is  kept  up, 
but  as  soon  as  the  physician  or  the  patient  stops  it,  the  old  condition 
again  returns. 

Among  the  remedies  with  a  local  action  are  also  included  moist 
compresses  upon  the  epigastrium,  either  in  the  form  of  the  simple 
Xeptune's  girdle  or  sedative  cataplasms  of  chamomile,  valerian,  etc. 

The  bromides  are  the  most  important  of  the  agents  which  act 
centrally  ;  we  may  use  either  the  salts  of  potassium,  sodium,  ammo- 
nium [or  strontium],  but  the  dose  must  be  large  to  obtain  a  good 
effect.  The  limit  is  about  two  to  three  grammes  [gr.  xxx-xlv]  two 
or  three  times  a  day ;  these  doses  are  usually  well  borne,  although 
some  patients  bear  even  small  doses  badly  ;  the  head  is  confused, 
the  limbs  feel  heavy ;  the  characteristic  smell  may  be  detected  in 
the  breath,  and  sometimes  there  is  even  incontinence  of  urine.  It 
is  therefore  advisable  to  begin  with  small  doses ;  and  in  every  case 
where  the  drug  has  been  used  for  long  periods  it  is  wise  to  make 
small  intermissions  in  its  administration  for  three  to  eight  days. 
Erlmeyer's  bromide  water  is  also  useful  here.  Antipyrin,  phenac- 
etin,  salicylic  acid,  and  salol,  in  doses  of  0*5  to  I'O  gramme  [gr. 
vijss.-xv]  are  beneficial  only  for  the  hemicrania  occurring  among 
the  other  gastric  symptoms  ;  but  otherwise  they  have  no  direct 
effect  on  the  nervous  apparatus  of  the  stomach. 

Rosenthal  employed  pilocarpine  subcutaneously  in  the  spastic 
forms  of  vomiting,  inferring  this  use  from  the  antispasmodic  action 
of  the  drug  in  obstinate  singultus.  From  a  similar  theoretical 
standpoint  we  may  recommend  physostigma,  the  central  paralyzing 
power  of  which  is  well  known,  and  which  was  recently  tried  by 
Riess  and  G.  Meyer.  In  several  cases  in  which  I  employed  this 
remedy  no  special  benefit  was  obtained. 

I  may  also  speak  here  of  the  valerianate  and  the  natrio-salicylate 
of  caffeine — in  doses  of  O*!  [gr.  jss.]  two  to  three  times  daily — also 
of  caffeine  chloral  and  of  nitroglycerin,  which  Talma  valued  so 
hi2:hly.  The  former  have  more  of  a  general  action  on  the  ex- 
hausted nervous  system,  and  are  at  the  same  time  cardiac.  In 
chloral  caffeine  the  sedative  and  analgesic  effect  of  the  chloral  is 
marked  ;  it  also  has  the  advantage  of  being  suitable  for  subcutaneous 
use.     I  have  discarded  nitroglycerin  on  account  of  the  frequent  oc- 


TREATMENT   OP   GASTRIC   NEUROSES.  553 

CTirreuce  of  unpleasant  after  effects,  headaches,  and  vascular  excita- 
tion. It  may  be  used  in  doses  of  0*5  milligramme  [gr.  y^^]  in  oil 
or  in  tablets. 

In  nearly  all  the  conditions  under  discussion,  a  general  toning 
of  the  constitution  by  improving  the  metabolism  and  the  composi- 
tion of  the  blood  is  indicated,  as  well  as  an  excitation  or  quieting  of 
the  nervous  system.  The  preparations  of  arsenic  and  iron  are  the 
best  for  this  purpose. 

Although  I  formerly  used  Fowler's  solution  most  frequently, 
yet  now,  in  accordance  with  Liebreich's  recommendation,  I  employ 
arsenous  acid  almost  exclusively,  either  in  solution  : 

^  Acidi  arsenosi 0'02  [gr.  ^] 

Aquse  menthae  piperitae 20*0    [f  3  v] 

M.     Sig.  :  Ten  drops  t.  i.  d.,  and  increase. 

It  may  also  be  administered  in  granules  of  one  milligramme 
[gr.  -q\],  or  in  the  form  of  Asiatic  pills  : 

[^  Acidi  arsenosi 0'075  [gr.  j|-] 

Pulveris  piperis  nigri 6*0  [  3  jss.] 

Gummi  arabici 1*5  [gr.  xxiij] 

Pulveris  radicis  althese 2*0  [gr.  xxx] 

Aquse  q.  s.  ut  fiat  pil.  no.  c. 

M.     Sig.  :  One  to  three  pills  t.  i.  d.] 

If  the  precaution  be  taken  of  avoiding  any  irritation  of  arsenic 
upon  the  mucous  membrane  by  giving  it  only  when  the  stomach  is 
full,  and  if  the  above  preparations  be  employed,  then  the  drug  can 
be  used  for  a  long  time  and  in  larger  doses  than  is  usually  possible 
— i.  e.,  up  to  10  to  15  milligrammes  [gr.  |-  to  ^]  per  day — vdthout 
any  bad  effects.  [Sawyer  *  has  also  highly  commended  the  use  of 
arsenic  in  gastralgia ;  he  prefers  to  use  it  in  pills  of  arsenous  acid, 
gr.  ^,  with  2  to  3  grains  of  extract  of  gentian,  three  times  daily 
between  meals.] 

The  mineral  waters  of  Roncegno  and  Levico  in  South  Tyrol  are 
excellent  means  of  giving  iron  and  arsenic.  Even  very  weak  and 
delicate  persons  may  continue  their  use  for  a  long  time,  provided 
they  begin  with  small  doses — a  tablespoonful  once  daily,  half  an 

*  [Sawyer.     London  Lancet,  July  4,  1896. — Ed.] 


554  DISEASES  OP  THE  STOMACH. 

hour  after  the  midday  meal,  and  gradually  increase  up  to  two  to 
three  tablespoonfuls  (see  page  438). 

Iron  is  also  usually  well  borne  when  combined  with  a  purgative. 
I  frequently  use  Dr.  Saundby's  formula  : 

]^     Ferri  sulphatis g-f-  ij  [0'12] 

Acidi  sulphurici  diluti ni  xv  [0*Y5] 

Magnesii  sulphatis gi"-  ^j  [0*55] 

Aqu8e  menthse  piperitse 5  j  [30*0] 

M.     Sig.  :  Tal.  dos.  thrice  daily. 

If  we  disregard  the  iron  waters,  the  best  way  of  adminigtering 
this  metal  is  in  combination  with  albuminates,  as  albuminate  of  iron. 
Ferruginous  preparations  are  as  abundant  as  the  sand  on  the  shore, 
and  every  form  has  found  its  panegyrist ;  but  the  preference  of  one 
above  the  other  depends  mostly  upon  individual  experience  and  co- 
incidences. I  use  almost  exclusively  the  chlorine  compounds  of 
iron,  to  the  ease  of  the  absorption  of  which  I  have  repeatedly  called 
attention — ^i.  e.,  the  tincture  of  the  chloride  of  iron ;  the  sesqui- 
chloride  of  iron  in  substance  (combined  with  arsenic  or  quinine  or 
chinoidin  in  pills) ;  or  liquor  ferri  sesquichlorati  (Ph.  G.)  [liquor 
ferri  chloridi,  U.  S.  P.]  mixed  together  in  2  to  5  per  cent  solution, 
and  given  in  teaspoonful  doses  with  white-of-egg  water  (1  part  of 
white  of  egg,  5  parts  water).  This  makes  an  albuminate  of  iron 
which  is  very  well  borne,  almost  without  exception,  even  by  very 
sensitive  stomachs,  and  may  replace  the  expensive  liq.  ferri  album. 
Drees  (Ph.  Glerm.).*  The  hsematogenous  remedies  may  be  com- 
bined with  the  so-called  tonics,  cinchona  bark,  and  the  other  bitters. 

The  various  hydriatic  procedures  must  be  considered  among 
those  methods  which  have  a  strengthening  as  well  as  a  soothing  in- 
fluence. These  include  the  methodical  use  of  lukewarm  half-baths, 
washing  the  whole  body  with  lukewarm  sprinkling  douches — ^the  so- 
called  Scotch  douches  f — packing  with  tepid  water,  and  cool  sitz- 

*  [Other  organic  iron  preparations  are  also  useful ;  they  may  be  given  alone  or 
in  combination  with  Fowler's  solution,  detannated  tinct.  nuc.  vomicae,  etc.  See 
also  Goodhart,  Rest  and  Food  in  the  Treatment  of  Ansemia  and  Anorexia  Nervosa. 
Amer.  Jour.  Med.  Sciences,  September,  1891,  p.  238. — Ed.] 

f  [The  Scotch  douche  consists  of  a  stream  of  water,  about  the  size  of  a  finger, 
which  is  directed  against  the  epigastrium.  The  temperature  of  the  water  is  rapidly 
alternated,  30°  C.  (86°  F.)  and  12°  C.  (54°  P.),  every  ten  to  twelve  seconds.    It  lasts 


TREATMENT   OF   GASTROPTOSIS.  555 

baths.  I  would  warn  against  tlie  nse  of  too  cold  water,  which  fre- 
quently has  an  exciting  and  irritating  effect ;  for  this  reason  cold 
river  and  sea  baths  may  sometimes  be  badly  borne.  To  make  an 
error  of  this  kind  in  a  feeble  and  anaemic  person  is  of  less  impor- 
tance than  it  would  be  in  the  by  no  means  insignificant  number  of 
neurasthenics  who  apparently  have,  or  miagine  that  they  have,  a 
strong  constitution,  and  hence  believe  that  the  more  the  cold  water 
causes  them  to  shiver  the  greater  will  be  its  healing  influence. 

At  this  place  I  wish  to  add  a  few  words  about  the  treatment  of 
gastrojttosis  and  enteroptosis.  The  object  of  the  treatment  is  two- 
fold, mechanical  on  the  one  hand  and  medicinal  and  dietetic  on  the 
other.  The  former  indication  is  met  by  means  of  a  properly  con- 
structed support  which  will  lift  up  and  hold  the  displaced  organs  in 
place.  According  to  Glenard,  the  indication  for  such  supports  is 
given  by  the  immediate  cessation  of  the  symptoms  and  a  decided 
feeling  of  relief  which  follow  when  the  abdominal  viscera  are  lifted 
up  even  momentarily.  This  is  accomplished  by  standing  behind 
the  patient,  grasping  the  abdomen  with  both  hands,  and  exerting 
pressure  from  below  upward  and  inward.  This  often  occurs,  and 
is  especially  marked  in  cases  of  pendulous  abdomens,  but  it  may 
also  be  observed  in  others  who  are  not  stout.  For  the  latter  it  is 
often  difficult  to  obtain  a  comfortable  support,  because  as  the  re- 
sult of  their  leanness  the  abdomen  is  usually  sunken  in  while  the 
pelvic  bones  are  very  protuberant.  Kuttner  and  myself  have  de- 
vised a  supporter  which  consists  of  a  slightly  curved  tin  shield,  the 
size  of  which  varies  according  to  that  of  the  abdomen  ;  this  is  pad- 
ded heavily  in  such  a  way  that  the  thickness  diminishes  from  below 
upward.  This  truss  is  retained  by  means  of  suitable  springs  and 
thigh  and  abdominal  strips  ;  the  lower  border  is  about  two  centi- 
meters [0-8  inch]  above  the  symphysis  pubis,  the  sides  the  same  dis- 
tance from  the  iliac  crests,  the  pressure  being  exerted  obliquely 

two  to  three  minutes,  and  may  or  may  not  be  followed  by  a  warm  pack.  The  alter- 
nation of  heat  and  cold  is  very  stimulating  to  the  entire  neuro-rauscular  apparatus 
of  the  digestive  tract.  At  the  same  time  it  causes  hypersemia  of  the  abdominal 
parietes  and  viscera.  Both  of  these  actions,  the  stimulating  and  the  vascular,  are 
increased  by  the  mechanical  effects  of  the  impact  of  the  stream  of  water  against 
the  skin.  Thus,  it  is  a  powerful  adjuvant  to  electricity  and  massage  of  the  abdo- 
men.   Ziemssen,  Klinische  Vortrage,  No.  sii,  1888. — Ed.] 


556  DISEASES  OF  THE   STOMACH. 

from  below  upward.  The  tension  of  tlie  abdominal  walls  is  in- 
creased, and  tlius  the  peristalsis  of  the  stomach  and  intestines  is  ren- 
dered easier  by  the  increased  support  which  is  thus  afforded  to  them. 
We  can  thus  easily  explain  the  surprising  improvement  which  is 
often  seen  after  wearing  such  supporters ;  a  good  proof  of  this  is 
the  fact  that  the  patients  never  do  without  them,  for  as  soon  as  they 
do  so  the  old  symptoms  return.  [Treves  *  has  recently  reported 
the  complete  cure  of  a  very  severe  case  of  gastroptosis  by  laparot- 
omy and  stitching  the  stomach.] 

In  the  way  of  drugs,  we  may  use  mild  vegetable  aperients  and 
the  neutral  salts  \_MiUelsalze\  to  secure  proper  evacuation  of  the 
bowels,  and  as  intestinal  disinfectants,  creosote,  benzo-naphthol,  and 
bismuth  salicylate.  Furthermore,  we  may  employ  the  general  tonic, 
dietetic,  and  gymnastic  measures  and  electricity,  all  of  which  have 
already  been  discussed. 

By  means  of  these  measures  excellent  results  may  frequently  be 
obtained  in  suitable  cases. 

In  a  certain  group  of  patients  with  nervous  stomach  troubles,  in 
whom  persistent  anorexia  has  led  to  very  profound  disturbances  of 
nutrition,  marked  emaciation,  and  enfeeblement  of  the  body,  the 
use  of  the  rest-cure  {Mast-hur)  is  to  be  recommended.  This 
method,  as  is  well  known,  was  first  introduced  by  Weir  Mitchell, 
and  modified  by  Playfair,  of  London,  and  Burkart,  Leyden,  and 
Binswanger,  in  Germany ;  its  object  is  to  introduce  and  cause  the 
absorption  of  a  quantity  of  food  which  the  patient  under  ordinary 
circumstances  is  able  neither  to  take  nor  to  assimilate.  With  this 
purpose,  the  treatment  consists  of  two  parts — a  psychical  and  a 
vegetative  or  dietetic.  The  object  of  the  former  is  to  remove  the 
patient  from  the  injurious  influences  which  his  surroundings  and  his 
usual  habits  of  daily  life  exert  upon  him,  these  being  adapted  to  his 
complaint ;  therefore,  he  is  kept  isolated  from  these  deleterious  fac- 
tors, so  that  he  is  completely  under  the  control  of  his  physician, 
whose  orders  he  must  obey  even  to  the  smallest,  apparently  trivial, 
details.     For  this,  it  is  absolutely  essential  to  separate  the  patient 

*  [Treves.    British  Med.  Journal,  January  4,  1896,  p.  1,— Ed.] 


REST-CURE  IN  GASTRIC   NEUROSES.  557 

from  his  family  and  heejp  him  at  a  sanitarium^.  1  must  confess 
that  I  did  not  formerly  lay  as  much  stress  on  treatment  in  a  sanita- 
rium as  I  do  now,  after  having  had  a  much  more  extended  expe- 
rience. This  is  not  alone  true  in  cases  of  the  rest-cure,  but  also  in 
many  other  neuroses,  which  offer  far  greater  chances  for  cure  when 
they  are  under  the  direct  care  of  the  physician  and  are  removed 
from  the  disturbing  influences  of  home  life.  I  therefore  insist  more 
and  more  upon  treating  these  cases  away  from  home.  I  also  lay 
stress  upon  the  cure  being  supervised  or  carried  out  by  only 
one  physician.  Two  doctors,  no  matter  how  well  they  harmonize, 
may  in  giving  orders  easily  disagree  on  trivial  details  which,  how- 
ever, appear  to  be  very  important  to  the  anxious  and  distrustful  pa- 
tient, and  may  thus  occasion  doubts  and  uncertainty.  It  is  just  in 
this  class  of  cases  that  absolutely  consistent,  certain,  and  unerring 
lines  of  treatment  are  essential. 

The  object  of  the  dietetic  measures  is  to  overfeed  the  patient — 
i.  e.,  at  least  during  the  early  part  of  the  treatment,  to  give  more 
nourishment  than  is  required  to  satisfy  his  subjective  wants.  Rest 
in  bed  is  essential  to  prevent,  as  far  as  possible,  the  conversion  of 
the  food  for  heat  production  and  muscular  work ;  but  at  the  same 
time  the  circulation  is  improved  by  passive  muscular  exercise 
through  massage  and  electricity. 

The  treatment  is  carried  out  as  follows :  The  first  step  is  to  iso- 
late the  patient  and  place  him  in  charge  of  a  male  or  female  nurse, 
whose  duty  it  shall  be  to  manage  the  feeding  and  the  above-men- 
tioned mechanical  procedures;  the  nurse  ought  also  to  have  the 
pleasant  quality  of  not  being  personally  unsympathetic  to  the  pa- 
tient. For  the  first  few  days  the  cure  consists  in  giving  milk  in 
small  quantities  at  two  or  three  hours'  intervals,  so  that  one  or  two 
litres  [quarts]  are  taken  daily ;  the  milk  may  be  raw  or  cooked, 
skimmed  or  fresh  from  the  cow,  warm  or  cold,  and  may  have  vari- 
ous additions  according  to  the  caprice  and  taste  of  the  patient. 
After  three  or  four  days  the  food  is  made  more  substantial  and  is 
given  in  small  amounts  every  two  hours.  This  consists  of  milk, 
meat,  farinaceous  food,  butter,  and  coffee  or  tea ;  the  daily  quantity 
should  be  about  2|  litres  [six  pints]  of  milk,  420  grammes  [  3  xiv] 
of  meat,  about  150  grammes  [  3  v]  of  vegetables  or  stewed  fruit, 


558  DISEASES  OF  THE  STOMACH. 

and  the  equivalent  amount  of  wheat  bread,  toast,  and  butter.  If 
the  stomach  rebels  against  this  rigorous  diet  and  reacts  with  an  acute 
gastric  catarrh — ^i.  e.,  dry,  coated  tongue,  belching,  heartburn,  pains 
in  the  stomach  and  head — then  it  must  be  suspended  for  a  few  days. 
Great  attention  must  also  be  paid  to  the  regulation  of  the  stools. 

In  favorable  cases  improvement  is  shown  as  early  as  the  second 
or  third  week.  After  the  third  or  fourth  week  the  patients  may 
leave  the  bed,  and  may  attempt  to  walk.  Corresponding  to  the 
progressive  improvement  the  massage  and  faradization  are  gradu- 
ally lessened  till  they  may  be  stopped  entirely.  If  no  improve- 
ment has  been  manifested  by  this  time,  it  is  advisable  to  refrain 
from  carrying  this  treatment  on  any  further.  As  an  example,  I 
may  mention  a  case  of  hysterical  anorexia  in  a  girl,  sixteen  years 
old,  which  had  developed  after  an  attack  of  scarlet  fever  eight  years 
previously.  The  patient  was  emaciated  to  a  skeleton,  and  suffered 
from  headaches,  tinnitus  aurium,  color-blindness,  and  photophobia, 
which  was  so  intense  that  she  had  to  sit  in  the  dark,  and  was  unable 
to  read  a  line  ;  great  lassitude  and  trembling  after  every  exertion  ; 
incontinence  of  faeces.  At  the  beginning  of  the  treatment  she 
weighed  25*6  kilogrammes  [56*3  pounds]  ;  the  conversion  of  nitro- 
gen as  calculated  for  albumen  was  3Y'19  grammes  [5Y3  grains]. 
At  first  she  received  as  food  114-42  grammes  [1T65  grains]  of 
albumen,  which  was  gradually  increased  in  four  weeks  to  195-77 
grammes  [3020  grains].  She  was  kept  isolated  from  December 
5th  to  January  26th ;  on  that  day  the  conversion  of  albumen  was 
124-06  grammes  [1914  grains] — i.  e.,  a  gain  of  71-71  grammes  [1106 
grains],  and  her  weight  was  33-05  kilogrammes  [72-7  pounds] — i.  e., 
an  increase  of  7-45  kilogrammes  [16*4  pounds].  I  have  had  the 
opportunity  of  watching  the  patient  three  months  longer;  she  is 
with  her  nurse  at  the  house  of  her  parents,  gains  steadily  in  weight, 
eats  well,  goes  out  walking,  and  is  free  from  her  old  symptoms ! 
This  splendid  result  was  obtained  only  because  during  the  entire 
course  of  treatment  she  was  free  from  all  kinds  of  gastric  and 
intestinal  disturbances,  except  those  of  a  very  slight  and  transient 
nature. 

The  important  factors  which  have  already  been  mentioned 
above,  and  which  have  also  been  emphasized  in  the  various  pub- 


REST-CURE  IN  GASTRIC  NEUROSES.  559 

lications  of  Burkart  (who  has  undoubtedly  Lad  the  largest  expe- 
rience in  this  field  of  any  one  in  Germany),  are  the  psychical  effect 
on  the  patient  and  the  latter's  firm  determination,  or  at  least  his 
consent,  in  favor  of  the  proposed  treatment.  If  both  of  these  are 
present,  we  may  disj)ense  with  isolation  in  a  hospital,  which  above 
all  has  a  psychical  effect,  provided  the  patient's  family  judiciously 
co-operate  with  the  method.  I  have  frequently  and  successfully 
carried  out  such  cures  at  the  patients'  homes,  and  know  that  others 
have  also  done  so.  ^Nevertheless,  I  adhere  to  what  I  have  already 
said  about  the  great  advantage  of  treatment  in  sanitaria.  But  one 
must  not  imagine  that  all  the  rest-cures,  even  in  sanitaria,  run  so 
smoothly  and  favorably  as  the  case  above  mentioned.  Many  pa- 
tients, in  spite  of  the  best  intentions,  are  unable  to  take  the  amount 
of  food  prescribed ;  for  they  either  vomit  it  or  they  may  even  be 
unable  to  swallow  solids.  In  such  cases  peptone  enemeta  also  are 
of  no  avail,  and  it  is  often  a  riddle  how  and  from  what  the  patients 
manage  to  survive.  Treatment  by  suggestion  (see  page  561)  I  have 
always  found  useless.  Other  patients  look  strong,  have  good  com- 
plexions, and  gain  correspondingly  in  weight ;  and  yet  in  spite  of 
all  this  they  have  the  same  lack  of  physical  and  mental  strength  as 
before.  One  of  my  patients  reported  as  follows  :  "  Every  mental 
relation,  for  example,  the  writing  of  this  letter,  is  a  very  severe  ex- 
ertion, and  walking  is  a  torture  to  me  on  account  of  the  weakness 
of  my  spine."  Others  keep  up  by  using  all  their  energies,  but, 
nevertheless,  make  no  real  progress.  Another  patient  wrote  to  me  : 
"  Your  orders  that  I  should  not  yield  to  the  moods  of  my  stomach 
are  my  best  aid.  I  force  myself  to  eat,  and  eat  my  beefsteak  with 
resignation  and  shudders,  in  order  to  keep  up  my  strength  until  I 
shall  feel  better."  * 

In  connection  with  this  therapeutic  measure  I  wish  to  call. atten- 
tion once  more  to  the  importance  of  systematic  weighing  in  the 
nervous  affections  as  well  as  in  all  lesions  of  the  organs  of  absorp- 
tion. Important  criteria  for  judging  the  course  of  a  disease  and 
the  success  of  our  treatment  may  be  obtained  by  the  increase  or  loss 
shown  by  the  scales  ;  the  latter  (loss)  must  also  frequently  include  a 

*  [For  further  details,  see  Weir  Mitchell,  Fat  and  Blood;  J.  M.  Mitchell,  Hare's 
System  of  Therapeutics,  vol.  i,  p.  227 ;  Thompson's  Dietetics,  p.  578. — Ed.] 


560  DISEASES  OP  THE   STOMACH. 

stationary  condition  of  the  weight  according  to  the  axiom,  "  Stand- 
still  is  retrogression."  The  only  precaution  necessary  is  not  to  be 
deceived  nor  influenced  by  small  and  inconstant  variations  in  the 
bodily  weight.  After  systematic  weighing  for  months  of  naked 
persons  who  have  been  kept  on  a  uniform  diet  and  surroundings, 
I  am  convinced  that  differences  of  1  to  IJ  kilogramme  [2|-  to  3-|- 
pounds],  from  one  day  to  another,  or  in  the  course  of  a  few  days, 
may  be  considered  normal  occurrences.  Even  continuous  consider- 
able losses  do  not  necessarily  indicate  a  bad  prognosis,  at  least  as 
long  as  the  correct  treatment  has  not  yet  been  discovered.  At  all 
events,  it  is  true  that  all  malignant  organic  structural  changes  are 
also  accompanied  by  constant  loss  of  weight,  with  possibly  small 
transient  fluctuations,  and  accordingly  always  have  an  unfavorable 
significance  ;  but  nervous  dyspeptics,  neurasthenics,  patients  with 
haemorrhoids,  and  the  like,  may  lose  15  to  20  kilogrammes  [33  to  44 
pounds]  within  a  few  months.  The  test  of  a  proper  and  successful 
treatment  consists  in  the  gradual  increase  of  the  bodily  weight  which 
is  sometimes  manifested  within  a  short  time  after  the  beginning  of 
the  new  regimen,  but  at  other  times  may  not  begin  till  after  a  period 
of  continual  loss  which  may  even  last  three  or  four  weeks.  There- 
fore, the  scales  ought  always  to  le  emjjloyed  in  all  hinds  of  stomach 
diseases,  hut  especially  in  the  neuroses.  Surely  all  should  imitate 
the  proposition  made  long  ago  by  the  late  Benecke,  that  every  one 
should  keep  a  regular  record  of  his  weight.  Prof.  Thomas  tried 
it  practically  on  himself,  with  excellent  results  for  regulating  his 
diet.* 

Finally,  the  treatment  of  the  gastric  neuroses  should  include  the 
use  of  all  those  adjuvants  which  improve  the  general  condition  and 
the  mind  by  the  effect  of  a  change  of  climate,  the  stimulating  and 
quieting  influence  of  the  air  of  mountains  and  plains,  sojourn  at  the 
seashore,  the  tonic  springs  like  the  alkaline  waters  of  Franzensbad, 
Ems,  and  E'euenaar ;  even  the  salines,  Wiesbaden  and  Kissingen ; 
the  mild  chalybeate  water  of  Elster,  Franzensbad,  Pyrmont,  Eip- 
poldsau,  and  the  like;  and,  last  but  not  least,  the  mud  baths. 
Probably  these  are  nowhere  better  nor  more  comfortably  prepared 

*  See  Transactions  of  the  Naturforscherversammlung  zu  Berlin,  1887. 


TREATMENT   OF   GASTRIC   NEUROSES.  561 

than  at  Franzensbad,  wliere,  as  even  Frerichs  said,  in  the  last  pub- 
hcation  which  came  from  his  pen,  there  is  an  abundant  supply  of 
material  for  their  preparation,  which,  having  been  carried  on  for 
years,  is  attended  to  with  the  utmost  care. 

Once  more  do  I  warn  against  the  pernicious  practice  of  ordering 
nervous  patients  to  use  the  Glauber's  salt  waters,  especially  those  of 
Carlsbad  and  Marienbad,  because  these  waters  are  very  slowly  and 
imperfectly  absorbed  in  these  cases — "  they  lie  heavily  in  the  stom- 
ach," and  exert  a  decidedly  enfeebling  effect ;  the  latter  is  due  to 
the  fact  that  they  involve  still  more  the  already  altered  metabolism, 
that  they  saturate  the  blood  with  neutral  salts,  which  are  improperly 
excreted,  and  that  not  alone  do  they  not  improt^e  tlie  nutrition  of 
the  nervous  system,  but  actually  injure  it.  At  the  end  of  every 
summer  I  regularly  see  numbers  of  such  patients  who  have  returned 
from  these  springs  with  a  decided  deterioration  of  their  condition. 

To-day  it  is  impossible  to  conclude  the  treatment  of  neuroses 
without  reference  to  suggestion  therapy.  Among  the  strict  adher- 
ents of  this  method  I  have  the  reputation  of  being  an  outspoken 
antagonist  because  I  endeavored  years  ago  to  estimate  the  proced- 
ures at  their  true  value,  and  therefore  was  lei  to  deny  to  liyj^no- 
tism  and  suggestion  the  qualities  of  remedial  agents  as  understood 
in  scientific  medicine.  I  did  this  because  their  successful  applica- 
tion demand  the  active  cooperation  of  the  patient  to  a  far  greater 
degree  than  is  usually  required  in  prescribing  a  remedy,  and,  fur- 
thermore, because  we  all  make  more  or  less  use  of  psychotherapy 
without  the  procedures  of  hypnosis  and  suggestion.  I  have  never 
denied  that  occasionally,  after  an  unusual  expenditure  of  such 
psychical  influences,  we  may  obtain  unusual  effects,  but  such  effects 
are  usually  only  of  transitory  duration,  l^evertheless,  I  have  em- 
ployed suggestion  in  so  many  cases,  either  trying  it  myself  or  with 
a  competent  "  hypnotiseur,"  that  I  have  formed  a  practical  opinion. 
This  is,  that  just  in  the  cases  of  severe  hysteria  in  which  we  have 
the  greatest  need  of  suggestion  we  are  left  in  the  lurch,  as  is  also 
admitted  by  Binswanger,*  after  a  very  large  experience,  because  hys- 
terical subjects  can  only  be  suggested  insufficiently  or  not  at  all.    At 

*  Binswanger.     Congress  fiir  innere  Medicin,  Leipzig,  1893. 


562  DISEASES  OF  THE  STOMACH. 

times  they  apparently  can  be  brought  into  the  first  stages  of  hyp- 
nosis, but,  as  may  easily  be  ascertained  by  careful  observation,  they 
never  relinquish  their  own  wills,  the  autonomy  of  their  minds  does 
not  cease,  and  the  suggestion  fails  to  accomplish  its  object.  In  other 
nervous  patients,  however,  without  resorting  to  hypnosis  we  can 
succeed,  with  the  good  will  of  the  patient,  by  employing  that  part 
of  suggestion  which  consists  in  energetic  and  firm  action,  and  may 
thus  dispense  with  this  procedure,  which  always  is  scarcely  edifying 
to  an  earnest  man.  Still,  I  will  not  deny  that  occasionally  sugges- 
tive influences  may  be  of  value ;  but,  as  I  have  already  said,  these 
results  are  not  permanent  in  the  majority  of  cases,  and  then,  as  I 
have  also  observed,  a  second  and  third  suggestion  no  longer  pro- 
duces any  effect. 


CHAPTEK  XII. 

THE  COEEELATION  OF  THE  DISEASES  OF  THE  STOatACH  TO  THOSE  OF 
OTHER  ORGANS. THE  PRACTICAL  VALUE  OF  THE  MODERN  CHEMI- 
CAL   TESTS. 

The  relations  which  exist  between  the  disturbances  of  digestion 
and  other  diseases,  as  I  need  scarcely  mention,  are  of  the  greatest 
importance.  There  is  hardly  any  internal  disorder  in  which  gastro- 
intestinal digestion  may  not  also  be  affected  to  a  greater  or  less 
degree ;  or  it  may  be  associated  with  them  by  functional  disturb- 
ances, the  treatment  of  which  is  to  be  conducted  upon  the  lines 
already  laid  down.  However,  my  present  aim  is  not  to  discuss  the 
changes  which  accompany  febrile  and  afebrile,  localized  and  consti- 
tutional processes,  but  rather  those  cases  of  disease  which  depart 
from  the  ordinary  course,  in  which  the  gastric  symptoms  are  the 
earliest  manifestations,  or  which,  at  least  on  superficial  observation, 
seem  to  be  the  prominent  features  of  pathological  processes  which 
are  situated  outside  of  the  stomach.  Here  it  is  of  the  utmost  im- 
portance to  discover  the  real  cause  of  the  digestive  disturbances,  to 
distinguish  the  secondary  features  of  the  disease  from  the  primary, 
and  to  recognize  them  as  such. 

The  effect  of  diseases  of  other  organs  upon  the  stomach  and  their 
reciprocal  action  as  manifested  in  structural  changes  in  this  organ 
have  been  carefully  studied  by  W.  Fen  wick.*  But  as  these  investi- 
gations are  concerned  with  the  pathological-anatomical  changes  in 
the  stomach  rather  than  with  the  clinical  features  of  these  processes, 
I  shall  here  simply  state  that  Fen  wick  calls  special  attention  to  the 
relation  between  advanced  atrophy  of  the  gastric  mucosa  and  perni- 
cious anaemia,  and  also  of  carcinomatous  tumors  of  other  organs, 

*  W.  Fenwiek,     Ueber  den  Zusammenhang  einiger  krankhafter  Zustande  des 
Magens  mit  anderen  Organerkrankungen.  Virchow's  Archiv,  1889,  Bd.  cxviii,  S.  187. 

563 


564  DISEASES  OP  THE  STOMACH. 

especially  tlie  mammary  gland  and  intestines ;  as,  for  example,  the 
occurrence  of  severe  anaemia  after  the  excision  of  relatively  insig- 
nificant tumors  of  the  breast.''^  However,  as  I  have  already  shown, 
Henry  and  Osier  f  and  other  writers  have  already  called  attention 
to  this  fact. 

W.  Fenwick  also  found  more  or  less  marked  catarrh  of  the 
mucous  membrane  of  the  stomach  in  nearly  all  the  diseases  which 
were  studied  by  him — i.  e.,  diseases  of  the  kidney,  pulmonary  phthi- 
sis, chronic  bronchitis,  emphysema,  various  valvular  lesions  of  the 
heart ;  it  was  least  marked  in  acute  pneumonia  and  typhoid  fever ; 
and  not  at  all  in  diseases  of  the  brain  (tumor,  epilepsy,  softening, 
apoplexy).  He  also  states  that  Handfield  Jones,:}:  in  a  study  of  over 
100  cases  of  "  affections  of  the  glands  of  the  stomach,"  only  once 
found  disease  of  the  brain.  If,  therefore,  the  gastric  symptoms, 
and  especially  vomiting,  which  occur  in  diseases  of  the  central  nerv- 
ous system,  are  manifestly  reflex  nervous  symptoms,  then  the  dis- 
turbances of  the  digestive  tract  which  occur  in  other  disorders  must 
undoubtedly  depend  upon  anatomical  and  functional  changes.  The 
most  important  of  the  latter  will  now  be  discussed. 

The  most  prominent  place  in  the  consideration  of  this  subject  is 
occupied  by  tuberculosis,  which  indeed  most  frequently  gives  rise  to 
errors.  It  i^  only  too  well  known  that  the  course  of  phthisis 
may  be  marked  by  dyspeptic  symptoms  which  may  vary  from  a 
simple  loss  of  appetite  to  severe  anorexia  and  vomiting,  and  may 
go  hand  in  hand  with  the  febrile  movement.  But,  as  Louis, 
Andral,  and  Bourdon  pointed  out  long  ago,  there  are  many  cases 
of  tuberculosis  in  which  the  first  symptom  to  attract  attention  is 
dyspepsia. 

Hutchinson  *  has  analyzed  a  large  number  of  cases  and  calcu- 
lated that  in  33  per  cent  dyspeptic  symptoms  precede  the  onset  of 
the  tubercular  manifestations.  W.  Fenwick  found  well-marked 
evidences  of  gastric  catarrh  in  11  out  of  15  cases  of  phthisis — 

*  Samuel  Fenwick.     Atrophy  of  the  Stomach.     London,  1880,  p.  49. 

f  Henry  and  Osier.     Atrophy  of  the  Stomach  with  the  Clinical  Features  of  Pro- 
gressive Pernicious  Anaemia.     American  Journ.  of  Med.  Sciences,  April,  1886. 
X  Handfield  Jones.     Diseases  of  the  Stomach. 

*  Hutchinson.  The  Morbid  States  of  the  Stomach  and  Duodenum.  London, 
1878. 


GASTRIC   SYMPTOMS   IN   TUBERCULOSIS.  565 

i.  e.,  T3  per  cent.  Marfan*  considers  this  figure  too  high,  and 
quotes  the  well-known  and  universally  accepted  observation  of 
Quenu  that  many  patients  disregard  the  period  of  short,  dry  cough 
which  precedes  the  onset  of  expectoration,  so  that  the  beginning  of 
the  disease  must  be  placed  at  an  earlier  period  than  is  given  by 
them.  In  61  cases  he  claims  to  have  found  only  five  in  which  the 
gastric  preceded  the  pulmonary  symptoms.  Yet  the  point  at  issue 
is  not  so  much  these  objections  to  the  patient's  previous  history  as 
the  fact  that  persons  frequently  consult  us  complaining  only  about 
their  digestion,  which  they  consider  the  cause  of  all  their  troubles ; 
yet  careful  examination  will  either  reveal  the  presence  of  a  phthisi- 
cal process,  or  will  cause  us  to  entertain  suspicions  of  such  a  condi- 
tion, the  correctness  of  which  is  confirmed  by  the  subsequent  course 
of  the  malady. 

As  a  rule,  these  patients  are  delicate  and  anaemic ;  they  begin  to 
complain  of  loss  of  appetite,  oppression,  and  fullness  after  eating, 
and  irregularity  of  the  bowels ;  they  suffer  from  regurgitation  and  a 
foul  taste  in  the  mouth ;  they  feel  feeble  and  languid.  For  a  long 
time  they  are  treated  for  chronic  catarrhal  gastritis ;  but  both  physi- 
cian and  patient  wonder  why  all  the  apparently  rational  remedies 
are  of  no  avail ;  then  a  careful  examination  is  made,  and  chronic 
puhnonary  disease  is  either  discovered  or  at  least  strongly  suspected. 
A  true  dullness  is  not  present,  yet  the  apices  do  not  expand  prop- 
erly, or  the  whole  of  one  side  may  expand  somewhat  tardily  on 
inspiration ;  the  respiratory  murmur  has  a  soft,  moist,  interrupted 
character ;  the  movements  of  the  entire  thorax  are  not  sufficiently 
deep;  the  manometer  shows  that  inspiration  and  expiration  are 
feeble;  expiration  is  prolonged.  Careful  questioning  will  now 
reveal  that  the  patient  has  "  hacked  "  for  a  long  time  without  pay- 
ing any  attention  to  it ;  that  he  was  scrofulous  as  a  child ;  that  he 
perspired  very  easily,  although  there  are  no  true  night-sweats ;  and, 
finally,  that  there  is  a  hereditary  predisposition.  If  we  can  obtain 
some  of  the  sputum — which,  when  the  expectoration  is  scanty,  the 
patient  frequently  disregards  or  swallows — we  may  often  succeed  in 
finding  a  few  tubercle  bacilli,  and  thus  at  once  corroborate  our  diag- 

*  B.  Marfan.     Troubles  et  lesions  gastriques  dans  la  phthisie   poulmonaire. 
Paris,  1887. 


566  DISEASES  OF  THE  STOMACH. 

nosis.  Under  these  circumstances  a  diseased  condition  of  the  stom- 
ach is  at  all  events  present,  yet  it  is  merely  the  manifestation  of  a 
venous  hypersemia  and  congestion,  which  in  its  turn  is  due  to  the 
disturbance  of  the  pulmonary  circulation. 

It  was,  therefore,  important  to  study  the  chemical  processes  of 
the  stomach  in  pulmonary  phthisis.  Some  incidental  communica- 
tions were  made  on  this  subject  by  Edinger,  and  also  by  myself ; 
yet  systematic  examinations  were  first  made  by  C.  Rosenthal,* 
Klemperer,f  Schetty,:}:  O.  Brieger,*  Hildebrand,  ||  and  Immer- 
mann ;  ^  their  results,  which  agree  tolerably  well,  are  best  expressed 
in  the  following  propositions,  formulated  by  Brieger : 

"  In  severe  cases  of  phthisis  a  normal  condition  was  found  in 
only  16  per  cent  of  the  cases,  in  the  rest  more  or  less  marked  in- 
sufficiency was  found  ;  in  fact,  in  9 '6  per  cent  of  all  the  cases  there 
was  a  complete  absence  of  all  the  normal  products  of  secretion, 

"  In  moderately  severe  cases  the  gastric  juice  was  normal  in  only 
33  per  cent ;  in  the  remainder  its  strength  varied,  the  disturbance 
being,  as  a  rule,  well  marked ;  while  in  6' 6  per  cent  the  normal 
secretory  products  were  absolutely  lacking. 

"  In  the  initial  stages  the  cases  of  normal  and  disturbed  secretion 
were  about  evenly  divided." 

Absorption  and  peristalsis  seem  to  be  impaired  to  a  degree  cor- 
responding to  the  disturbance  of  the  chemical  functions. 

It  is  self-evident  that  the  above  percentages,  which  are  based 
upon  64  cases,  give  an  approximate  and  not  an  absolute  idea  of  the 
relative  frequency  of  the  conditions  under  discussion.  After  care- 
ful study,  with  reliable  methods,  Grusdew  ^  and  Bernstein  ^  also 

*  C.  Rosenthal.  Ueber  das  Labferment.  Berliner  kiln.  Wochenschr,,  1888,  No. 
45. 

t  Klemperer.     Ueber  die  Dyspepsie  der  Phthisiker.     Ibid.,  1889,  No.  11. 
X  Schetty,  loc.  cit. 

*  0.  Brieger.  Ueber  die  Functionen  des  Magens  bei  Phthisis  piilmonum 
Deutsche  med.  Wochenschr.,  1888,  No.  14. 

II  H.  Hildebrand.     Ibid.,  1889,  No.  15. 

^  Immerraann.  Verhandlnngen  des  Congresses  fur  innere  Medicin.  Wies- 
baden, 1889. 

()  [Grusdew.  Wratsch,  1889,  Nos.  15,  16.  Centralblatt  fiir  klin.  Med.,  1890,  S. 
92.— Ed.] 

1 1  wan  Bernstein.  Die  Dyspepsie  der  Phthisiker.  Inaug.  Dissert.  Dorpat, 
1889. 


GASTRIC   SYiMPTOMS  IN   TUBERCULOSIS.  567 

come  to  the  conclusion  that  "  hydrochloric  acid  is  either  absent  or 
reduced  to  very  small  quantities." 

In  testing  the  motor  functions  Immermann  found  no  marked 
changes  in  53  out  of  54  trials — i.  e.,  the  stomach  was  found  empty 
six  hours  after  taking  Leube's  test  meal ;  on  the  other  hand,  Klem- 
perer  used  his  oil  method  (page  81),  and  found  a  marked  enfeeble- 
ment  of  the  motility.  Furthermore,  Immermann  states  that  he 
found  free  hydrochloric  acid  in  38  out  of  44  trials,  even  where  the 
high  fever  and  cachexia  of  the  terminal  stages  of  phthisis  were  pres- 
ent ;  Brieger  observed  it  only  in  16  to  33  per  cent.  This  discrep- 
ancy can  be  explained  by  the  former  having  used  Jaworski's  test 
breakfast  (the  whites  of  two  hard-boiled  eggs  and  100  c.  c.  [f  5  iij 
3  ij]  of  water),  which  is  notoriously  inadequate  for  this  purpose. 

At  all  events,  the  occurrence  of  gastric  disturbances  depends  on 
what  stage  of  phthisis  may  be  present.  Thus,  Hutchinson  states 
that  in  9  cases  dyspepsia  was  found  after  the  pulmonary  symptoms 
had  began ;  in  10  it  appeared  at  the  same  time,  and  in  33  it  pre- 
ceded them. 

Although  all  these  investigations  give  us  important  information, 
yet  their  value  would  have  been  greatly  enhanced  had  the  observers 
laid  more  stress  on  the  comparison  between  the  subjective  com- 
plaints and  the  results  of  the  objective  examinations.  It  is  beyond 
doubt  that  the  so-called  phthisical  dyspepsia  is  not  due  to  a  tubercu- 
lar affection  of  the  gastric  mucous  membrane,  but,  as  already  stated, 
is  only  a  complication  of  this  disease  due  to  disturbance  of  the  cir- 
culation. But  it  is  equally  certain  that  a  very  large  proportion  of 
the  successful  results  of  the  treatment  in  pulmonary  phthisis  de- 
pends on  the  nutrition  of  the  patient  and  the  possibility  of  main- 
taining it.  The  French  method  of  overfeeding  {but -alimentation) 
— the  experiences  of  Dettweiler,  Peiper,  Blihle,  Liebermeister,  Ley- 
den,  and  others — are  the  beet  proofs  of  this.  Our  therapeutic 
efforts  will  have  a  greater  effect  and  will  be  more  certain  if  we  have 
ascertained  the  functional  activity  of  the  digestive  organs  by  means 
of  a  chemical  examination  independently  of  any  of  the  patient's 
subjective  complaints.  True,  it  is  self-evident  that  the  first  object 
of  treatment  is  the  primary  disease,  with  the  improvement  or  cure 

of  which  the  dyspeptic  symptoms  will  disappear ;  yet  we  must  not 
37 


568  DISEASES  OF  THE  STOMACH. 

lose  sight  of  the  fact  that  the  improvement  of  the  functions  of 
the  stomach  with  the  resulting  better  state  of  nutrition  will  react 
favorably  upon  the  local  process  in  the  Imigs. 

Here  it  should  be  observed  that  the  specific  stomachics  are  un- 
successful, if  not  injurious,  for  thej  irritate  the  already  congested 
mucous  membrane,  and  thus  increase  the  hypersemia.  It  would  be 
much  more  advisable  to  lessen  the  irritating  effects  of  the  food,  as 
far  as  possible,  by  ordering  a  simple,  easily  digestible  diet,  or  by 
giving  in  each  individual  case  the  drugs  which  may  seem  to  be  indi- 
cated by  the  results  of  the  examination  of  the  gastric  functions,  pro- 
vided pronounced  dyspeptic  disturbance  should  render  this  necessary. 
A  general  rule  for  these  remedies  can  not  be  given,  as  is  at  once 
evident  after  a  careful  consideration  of  the  changeable  factors  here 
concerned.  Thus,  in  a  large  number  of  examinations  on  one  patient 
at  the  Augusta  Hospital,  Rosenthal  could  never  find  free  hydro- 
chloric acid  during  the  summer,  yet  when  he  returned  to  the  hospi- 
tal in  the  winter  it  was  present  in  abundance ;  Hildebrand  observed 
the  same  thing  during  shorter  periods.  Only  this  much  is  certain, 
that  the  subjective  complaints  of  the  patient  do  not  by  any  means 
always  correspond  to  the  results  of  the  objective  examination,  and 
that  therefore  the  former  should  be  investigated  before  they  are 
allowed  to  weigh  against  methods  of  treatment  which  (like  the  ali- 
msntation  force  of  the  French)  aim  to  improve  the  general  nutrition 
by  giving  larger  quantities  of  food.  Concerning  the  milk  diet,  we 
should  remember  that  its  power  of  combining  with  acids  surely 
comes  into  play  in  the  cases  or  stages  of  hyperacidity  which  have 
been  mentioned  above. 

But,  to  return  to  the  question  under  discussion,  these  cases  of 
pretubercular  dyspepsia — if  we  may  use  this  short  but  improper 
expression — ^may  be  readily  recognized,  provided  sufficient  care  be 
exercised.  The  diagnosis  is  not  so  easy  if  the  dyspeptic  symptoms 
are  due  to  a  centrally  located  miliary  tuberculosis  with  slight  feb- 
rile movement.  If  this  is  associated  with  a  moderate  enlargement 
of  the  spleen,  of  recent  or  old  origin,  it  may  readily  be  mistaken  for 
typhoid  fever,  especially  the  ambulant  variety.  I  recently  saw  an 
example  of  this  in  a  gentleman  from  St.  Petersburg,  who  thought 
his  stomach  was  at  fault.     He   presented  the  group  of  symptoms 


GASTRIC  SYMPTOMS  IN  TUBERCULOSIS.  569 

juBt  described :  there  was  a  moderate  irregular  febrile  movement, 
with  slight  evening  exacerbations,  which  was  said  to  have  existed 
for  some  time,  since  quinine,  antipyrine,  and  hydrochloric  acid  had 
been  prescribed  for  him.  Inasmuch  as  he  said  that  he  had  been 
suddenly  taken  ill  some  weeks  previously  after  a  journey  in  a  fever 
district,  and  had  nevertheless  not  gone  to  bed,  but  instead  had 
attended  to  his  business,  I  naturally  thought  of  the  last  stage  of 
a  "  walking  typhoid  fever "  with  an  irregular  febrile  movement ; 
all  doubt  was  dispelled  during  about  the  fourth  week,  when  the 
symptoms  of  acute  miliary  tuberculosis  became  more  and  more 
prominent.  He  died  of  undoubted  pulmonary  tuljerculosis  after 
having  been  a  few  weeks  at  Gorbersdorf. 

[Fenwick  *  has  made  a  very  careful  study  of  the  condition  of 
the  stomach  in  pulmonary  phthisis.  He  distinguishes  a  prodromal, 
initial  and  final  dyspepsia  of  phthisis,  and  has  presented  data  con- 
cerning the  forms  as  he  found  them  in  an  analysis  of  a  large  num- 
ber of  cases.  The  prodromal  dyspepsia  he  subdivides  into  the 
atonic  and  irritable  varieties,  the  former  occurring  usually  in  young 
females  from  thirteen  to  twenty -five  years  of  age,  the  latter  in  men 
from  twenty-five  to  forty  years  old.  The  atonic  form  usually  follows 
convalescence  from  some  acute  febrile  disorder,  or  may  begin  insidi- 
ously. The  difference  in  the  symptoms  in  the  two  groups  is  sufli- 
ciently  expressed  by  their  names. 

The  initial  dyspepsia  is  that  which  ushers  in  and  accompanies 
the  first  stage  of  pulmonary  phthisis,  and  is  that  which  is  usually 
known  as  the  dyspepsia  of  phthisis.  It  seems  to  be  much  more  com- 
mon in  women  than  in  men.  Pain  is  a  very  constant  feature,  since 
it  was  noted  in  92  per  cent  of  the  cases  ;  vomiting  also  occurs  fre- 
quently ;  the  appetite  is  distended,  especially  toward  evening.  There 
is  a  marked  repugnance  toward  fat.  Other  symptoms  are  flatulence, 
acidity,  constipation,  large,  flabby,  indented  tongue,  and  profound 
anaemia.  The  symptoms  stand  in  a  direct  relation  to  the  condition 
of  the  lungs,  and  may  even  be  arrested  if  the  pulmonary  disease  is 
cured. 

The  final  dyspepsia  is  that  which  occurs  after  the  formation  of 

*  [W.  Soltan  Fenwick.    The  Dyspepsia  of  Phthisis,  its  Varieties  and  Treatment. 
London,  1894.— Ed.] 


570  DISEASES  OP  THE  STOMACH. 

cavities  in  tlie  lungs.  Here  also  women  seem  to  be  more  frequently 
attacked,  tlie  ratio  being  62  per  cent  in  women,  25  per  cent  in  men. 
The  cliief  symptoms  are  anorexia,  thirst,  painful  sensations  in  the 
epigastrium,  and  nausea.  Yomiting  and  llatulance  are  not  constant 
as  in  the  other  forms.     The  bowels  are  irregular. 

Fenwick  lays  great  stress  on  the  fact  that  the  stomach  is  not 
alone  involved,  but  the  entire  intestinal  tract  as  well.  It  is  really  a 
gastro-enteritis  which  begins  in  the  chronic  interstitial  form,  which 
is  due  to  the  absorption  of  certain  toxic  substances.  Later  on  the 
glands  are  also  involved.  This  condition  can  always  be  demon- 
strated after  cavities  have  been  formed  in  the  lungs.  For  further 
details,  this  excellent  monograph  may  be  consulted.  For  tubercular 
ulcers  of  stomach,  see  pages  401  and  418]. 

The  changes  in  the  digestive  tract  in  ansemia  and  chlorosis  are 
closely  allied  to  the  above.  They  undoubtedly  play  an  important 
part,  which,  up  to  the  present  time,  has  been  very  much  neglected  ; 
hence,  in  the  treatment  of  anaemia,  efforts  should  first  be  made  to 
improve  the  condition  of  the  digestive  organs,  and  then  the  compo- 
sition of  the  blood.  As  has  long  been  known,  and  as  Hayem,* 
Gluczinsky,f  Pick,;}:  and  others  have  shown  by  direct  examination 
of  the  gastric  juice  and  the  functions  of  the  stomach,  a  true  insuffi- 
ciency of  the  latter  exists.  [Osswald  *  has  recently  examined  21 
chlorotic  patients  ;  free  HCl  was  present,  usually  in  excess  ;  at 
times  the  percentage  was  as  high  as  160.  The  motor  functions  were 
normal].  But  some  writers,  especially  Hayem,  go  too  far  when  they 
consider  that  the  changes  in  the  stomach  and  intestines  are  the  pri- 
mary cause.  In  my  opinion,  it  is  one-sided  to  claim  that  chlorosis 
can  be  cured  by  the  relief  of  these  disturbances ;  for  it  is  by  no 
means  certain  that  these  changes  in  the  digestive  tract  are  not  sec- 
ondary, and  can  only  be  relieved  after  the  composition  of  the  blood 


*  Hayem.  Des  alterations  du  ehimisme  stomaeal  dans  la  ehlorose.  Bulletin 
medic,  1891,  No.  87. 

f  Buczlygan  und  Glnczinsky.  Ueber  das  Verhalten  des  Magensaftes  bei  den 
verschiedenen  Formen  der  Anaemia  und  besonders  der  Chlorose.  Internat.  klin. 
Rundschau,  1891,  No.  34. 

X  Pick.     Therapie  der  Chlorose.     Wiener  med.  Woehenschr.,  1891,  No.  50. 

*  [Osswald.  Ueber  den  Salzsauregehalt  des  Magensaftes  bei  Chlorose.  Miinch. 
med.  Woehenschr.,  1894,  No.  37.— Ed.] 


GASTRIC  SYMPTOMS  IN  HEART  DISEASE.  571 

has  been  improved  bj  appropriate  treatment.  The  histories  of 
many  patients  attest  the  truth  of  this. 

[Meinert  *  maintains  that  many  cases  of  chlorosis  are  due  to  gas- 
troptosis.  He  does  not  include  all  young  women  with  chlorosis,  as 
has  been  generally  supposed,  but  only  such  girls  who  up  to  the  time 
of  puberty  had  been  apparently  in  good  health.  In  all  of  these  cases 
Meinert  states  that  inflation  of  the  stomach  has  always  demonstrated 
the  presence  of  gastroptosis.  The  prolapse  of  the  stomach  produces 
a  stretching  of  the  gastric  nerves,  which  in  turn  irritates  the  solar 
plexus.  The  latter  giving  off  sympathetic  branches  to  the  spleen, 
may  disturb  the  blood  formation  which  occurs  in  the  latter  organ. 
The  most  fruitful  cause  of  gastroptosis  is  tight  lacing.  Meinert's 
monograph  is  most  elaborate,  and  contains  many  typical  examples 
of  this  condition. 

This  subject  has  been  studied  by  Kelling,f  Briiggemann,:}:  and 
Meltzing,*  all  of  whom  agree  that  Meinert  is  too  sweeping  in  his 
assertions,  and  that  gastroptosis  is  not  present  in  all  cases  of  "  typical 
chlorosis,"  as  described  by  him.  They  agree,  however,  that  down- 
ward displacement  of  the  stomach  is  of  frequent  occurrence  in  chlo- 
rosis, and  seems  to  be  found  more  frequently  in  these  subjects  than 
in  non-chlorotic  girls.] 

The  next  group  of  diseases  includes  the  valvular  affections  of 
the  heart.  Here,  also,  the  nature  of  the  lesion  causes  a  venous  con- 
gestion and  the  symptoms  of  a  chronic  catarrh  of  the  stomach. 
Careful  examination  is  required  to  reveal  incompetency  of  the 
valves,  enlargement  of  the  heart,  latent  pericarditis,  pericardial  ad- 
hesions, or  chronic  myocarditis.  In  such  cases  cures  can  only  be 
effected  in  the  early  stages  ;  unfortunately,  these  therapeutic  meas- 
ures usually  afford  temporary  and  not  permanent  relief  ;  yet  some- 
times, by  using  digitalis  and  other  members  of  this  group  for  a  short 
time,  we  may  succeed  in  completely  removing  the  catarrhal  mani- 
festations, and  thus  secure  a  period  of  relative  or  absolute  relief. 

*  [Meinert.     Volkmann's  klinische  Vortrage,  Nos.  115  and  116,  January,  1895. — ■ 
Ed.] 

t  [Kelling.     Ibid.,  No.  144,  February,  1896.— Ed.] 

X  [Briiggemann.     Ueber  den  Tiefstand  des  Magens  bei  Clilorose.    Inaug.  Dissert. 
Bonn,  1895.— Ed.] 

*  [Meltzing.     Wiener  raed.  Presse,  1895,  No.  30.— Ed.J 


572  DISEASES  OP  THE  STOMACH. 

A  priori,  there  can  be  scarcely  any  douht,  for  the  reasons  above 
given,  that  tlie  secretory  activity  of  the  stomach  is  lessened  as  soon 
as  compensation  is  disturbed,  not  alone  in  true  valvular  lesions,  but 
also  in  other  processes  which,  directly  or  indirectly,  cause  functional 
disturbances  of  the  cardiac  muscle.  Hiiiier*  thought  that  he  had 
proved  this,  since,  in  10  cases  of  the  above  kinds,  mostly  valvular 
lesions,  total  absence  of  hydrochloric  acid  and  almost  negative  di- 
gestion of  albumen  were  found  9  times,  in  spite  of  the  fact  that 
most  of  the  patients  were  still  in  the  clinical  stage  of  complete  com- 
pensation. In  the  single  patient  (moderate  mitral  insufficiency)  in 
whom  hydrochloric  acid  was  present,  he  is  inclined  to  assume  "  hy- 
peracidity." But  concerning  this  apparently  exceptional  case  it 
may  be  stated  that  it  is  by  no  means  certain  that  congestion  of  the 
gastric  mucosa  and  its  consequences  always  occur  under  these  cir- 
cumstances, for  there  may  also  be  a  compensation  in  the  stomach. 
Therefore,  the  assumption  of  hyperacidity  seems  unnecessary  to  me 
in  the  explanation  of  this  exception.  I  also  have  had  a  patient  with 
mitral  insufficiency  at  the  Augusta  Hospital,  the  acidity  of  whose 
stomach  contents  was  62  ;  the  acidity  was  entirely  due  to  HCl. 

But  it  appears  that  insufficiency  of  the  gastric  secretion  is  not 
as  constant  as  Hiifler  supposed  ;  for,  in  20  patients  with  heart  dis- 
ease, Adler  and  Stern  f  found  that  free  hydrochloric  acid  was  always 
present  in  16,  variable  in  2,  and  always  absent  in  2  cases.  I*^at- 
urally  these  writers  are  inclined  to  believe  that  this  discrepancy  is 
due  to  the  difference  in  the  methods  employed,  for  Hiifler  gave 
Leube's  meal  in  the  morning — i.  e.,  a  very  unfavorable  time — while 
Adler  and  Stern  gave  the  test  breakfast.  However,  it  is  also  prob- 
able that  the  degree  of  compensation  is  also  of  importance  in  this 
question,  for  the  clinical  picture  alone  does  not  enable  us  to  judge 
it  properly. 

The  diseases  of  the  kidney  also  involve  the  stomach  if  the  excre- 
tory products  of  the  metabolism  are  retained  in  the  organism  early 
in  the  course  of  the  affection ;  if  excreted  in  the  stomach  and  intes- 


*  Hiifler.  Ueber  die  Functionen  des  Magens  bei  Herzfehlern.  Miinch.  med. 
Wochenschr.,  1889,  No.  33. 

t  Adler  and  Stern.  Ueber  die  Magenverdauung  bei  Herzfehlern.  Berl.  kiln. 
Wochenschr.,  1889,  No.  49. 


GASTRIC  SYMPTOMS  IN  RENAL   DISEASES.  573 

tines,  thej  will  irritate  these  viscera.  Such  cases  are  by  no  means 
common ;  the  vomiting  and  other  symptoms  of  disturbances  of  gas- 
tric digestion  occur  long  before  the  distinct  signs  of  dropsy  or  other 
manifestations  which  would  lead  to  the  correct  diagnosis ;  hence, 
these  cases  are  thought  to  be  independent  lesions,  whereas  they  are 
really  only  due  to  chronic  uraemia.  They  may  also  occur  without 
any  disease  of  the  renal  parenchyma  where  there  has  been  a  long- 
standing retention  of  urine  from  obstruction  of  the  urinary  passages. 
Feuwick  *  assumes  that  the  mucous  membrane  of  the  stomach  can 
excrete  certain  poisons,  including  also  urea ;  the  result  of  this  irri- 
tation is  an  acute  catarrh  of  the  gastric  glands.  Degenerative  pro- 
cesses, for  example,  fatty  degeneration  of  the  glandular  epithelium 
and  amyloid  of  the  mucosa,  may  also  occur,  as  well  as  gastritis  in  the 
true  sense  of  this  term.  Biernacki  f  lays  stress  upon  the  retention 
of  metabolic  products  which  lessen  the  secretion  of  the  gastric  juice 
by  means  of  nervous  influences.  He  has  actually  demonstrated  this 
in  a  number  of  cases  of  nephritis  which  were  investigated  for  this 
purpose.  Therefore,  he  agrees  with  me :{:  in  recommending  pep- 
tonized milk  in  these  cases, 

[Zipkin  *  and  Alapy  !|  have  recently  studied  the  condition  of  the 
stomach  in  renal  diseases.  The  former  found  no  constant  relation 
between  the  two  organs ;  Alapy,  on  the  contrary,  asserts  that  the 
results  of  treatment  show  that  the  stomach  suffers  in  chronic  ne- 
phritis, probably  through  the  excretion  of  the  retained  nitrogenous 
substances  through  the  gastric  mucosa.  He  therefore  advises  the 
examination  of  the  urine  of  all  patients  over  fifty  years  of  age  with 
chronic  gastric  symptoms,] 

Eenal  tumors,  especially  carcinoma  of  the  kidney,  may  for  a 
long  time  cause  only  disturbances  of  digestion,  anorexia,  vomiting, 
and  emaciation ;  in  fact,  in  a  case  reported  by  CoUeville,"^  up  to  the 

*  Penwick,  loc.  cit. 

f  Biernacki.     Ueber  das  Verhalten  des  Magens  bei  Nierenentziindung.     Berl. 
klin.  Wochenschr.,  1891,  Nos.  35,  36. 

\  Ewald,     IX.  Congress  flir  innere  Medicin  z\\  Wien,  1890. 

*  [Zipkin.     Ueber  das  Verhalten  des  Magenverdauung  bei  Nephritis.     Inaug. 
Dissert.     Wurzburg,  1894.— Ed.] 

II  [Alapy.  Verdauungstorungen  bei  der  chronischen  Harnretention.  Wiener 
klinik,  1894.  No.  9.— Ed.] 

^  CoUeville.     Progr.  med.,  1883,  No,  20. 


574  DISEASES  OF   THE   STOMACH. 

patient's  death  these  were  the  only  symptoms.  Finally,  without 
suffering  any  changes  in  the  [renal]  secretory  capacity,  the  kidneys 
may  cause  disturbances  and  pain  in  the  stomach  on  account  of  their 
unusual  site  or  mobility ;  these  effects  of  floating  kidneys,  etc.,  have 
been  considered  while  discussing  gastroptosis,  gastrectasis,  and  gas- 
tralgia. 

The  liver  stands  in  such  close  relationship  to  the  stomach  [as  has 
already  been  discussed  in  Chapter  lY]  that  serious  functional  disturb- 
ances of  the  one  are  without  exception  reflected  on  the  other ;  this 
close  connection,  and  the  fact  that  so  many  of  the  noxious  substances 
introduced  from  without  act  on  both  viscera  at  once — I  will  only 
mention  alcohol — render  it  very  difficult  to  say  which  is  affected 
first.  For  example,  in  the  very  great  majority  of  cases,  cirrhosis  of 
the  liver  is  accompanied  by  chronic  gastritis,  yet,  even  if  we  observe 
that  the  symptoms  of  a  doubtful  hepatic  cirrhosis  have  for  a  longer 
or  shorter  time  preceded  a  chronic  gastric  catarrh,  we  are  utterly 
unable  to  tell  whether  the  two  stand  in  a  causal  relation  or  are 
simply  coincident.  I^evertheless,  we  should  never  forget  the  fact 
that  many  cases  of  hepatic  cirrhosis  for  a  long  time  run  their 
course  as  chronic  gastritis,  and  that  the  same  is  true  of  cancer  of 
the  liver. 

Although  I  have  frequently  called  attention  to  the  relations  of 
the  diseases  of  the  central  nervous  system  with  those  of  the  stomach, 
yet  I  must  not  neglect  to  take  this  subject  up  once  more  at  this 
place.  On  account  of  its  great  importance,  I  shall  only  specially 
discuss  the  relation  of  the  gastric  disturbances  to  sclerosis  of  the 
posterior  columns  of  the  spinal  cord  (tabes).  This  includes  not  only 
the  classical  attacks  of  gastralgia  and  gastric  crises  [see  page  403] 
which  occur  in  cases  well  advanced  and  recognizable,  but  also 
vaguer  sensations — slight  boring  and  radiating  pains,  a  permanent 
feeling  of  gnawing  and  burning  in  the  stomach,  or  even  more 
marked  perceptions  which  occur  among  the  prodromata,  or  as  the 
first  symptoms  of  locomotor  ataxia,  but  which  at  the  time  in  ques- 
tion have  not  yet  acquired  any  typical  characteristics.  It  is  self- 
evident  that  it  is  impossible  to  make  an  exact  diagnosis  under  such 
circumstances,  and  that  even  if  the  gastralgia  continue  for  years 
their  true  origin  would  not  be  recognized. 


GASTlilO  SYMPTOMS  IN  NERVOUS  DISEASES.  575 

Such  a  case  lias  been  described  by  Werner ;  *  an  induration  was 
found  at  the  pylorus  in  a  patient  who  had  been  for  a  long  time  con- 
sidered hysterical ;  gastro-enterostomy  was  performed  for  supposed 
stenosing  cicatrix  of  an  ulcer  at  the  pylorus ;  but  it  proved  to  be 
simply  a  muscular  hypertrophy.  As  the  operation  proved  unsuc- 
cessful, the  ovaries  were  subsequently  removed  (Hegar's  method} ; 
nevertheless,  the  gastric  symptoms,  which  were  chiefly  manifested 
as  gastralgia,  persisted  ;  and  it  was  only  five  years  later  that  distinct 
symptoms  of  tabes  appeared,  the  existence  of  which  was  confirmed 
at  the  autopsy.  Unfortunately,  the  early  symptoms  of  tabes  do  not 
readily  permit  a  positive  diagnosis ;  thus,  for  example,  the  absence 
of  the  patellar  reflex  occurs  independently  of  this  disease  so  fre- 
quently that  the  simple  coincidence  of  this  symptom  and  gastralgia 
in  a  suspicious  case  would  not  justify  a  diagnosis  of  locomotor 
ataxia. 

[A  case  has  recently  come  under  my  observation  in  which  gas- 
tralgic  attacks  existed  for  eight  years  before  the  real  nature  of  the 
disease  was  discovered.  At  present  the  symptoms  of  tabes  are  ab- 
sence of  patellar  reflexes,  Argyll-Robinson  pupils,  Romberg's  symp- 
tom, occasional  shooting  pains  in  the  lower  extremities,  and  attacks  of 
severe  gastralgia,  which  come  on  at  varying  intervals  and  last  from 
a  few  hours  to  a  few  days.  Repeated  examination  of  the  stomach 
contents  shows  normal  conditions  in  the  intervals  between  the  at- 
tacks, but  during  them  there  is  marked  subacidity.  For  a  long 
time  the  only  other  symptom  present  was  the  myosis,  which  caused 
her  to  be  unjustly  regarded  as  a  morphinist. 

"Wolff  f  has  also  carefully  described  three  cases  of  tabes  which 
had  been  under  his  observation  for  a  long  time,  in  which  the  gastric 
crises  were  not  alone  the  initial  but  also  were  the  most  prominent 
symptoms  throughout  the  disease.  At  all  times,  both  during  and 
between  the  attacks,  he  found  either  lessening  or  absence  of  HCL] 

Among  the  constitutional  diseases  diabetes  gives  rise  to  errors 
most  frequently.  For  years  many  diabetics  are  considered  to  be 
suffering  from  some  stomach  trouble  until  the  urine  is  examined, 

*  G.  Werner.  Gastrische  Krisen  als  Initialsymptom  einer  Tabes  dorsalis.  In- 
aug.  Dissert.     Berlin,  1889. 

•  \  [L.  Wolff.     Abstract  in  Boas's  Arch.,  Bd.  i,  p.  110.— Ed.] 


576  DISEASES  OP   THE  STOMACH. 

either  accidentally  or  on  account  of  the  development  of  the  specific 
symptoms  of  emaciation,  pruritus,  etc.  [Gastric  crises,  which  are  at 
times  very  painful,  have  also  been  reported  in  this  disease.*] 

In  well-developed  cases  of  diabetes,  as  shown  by  Eosenstein  f 
and  Gans,:}:  the  gastric  functions  are  very  variable,  and  stand  in  no 
relation  to  the  amount  of  sugar,  acetone,  and  diacetic  acid  in  the 
urine.  Eosenstein  concludes  from  his  investigations  that  in  some 
cases  free  hydrochloric  acid  may  be  absent ;  where  this  is  temporary, 
it  is  to  be  referred  to  a  gastric  neurosis  ;  but,  when  it  is  permanent, 
the  cause  is  atrophy  of  the  mucosa  in  consequence  of  interstitial 
inflammation. 

The  relations  of  g^out  to  disturbances  of  digestion  have  been 
especially  discussed  in  English  medical  literature.  According  to 
some  writers,  there  is  a  specific  gouty  disorder  of  the  stomach  re- 
sulting from  the  uric  acid  diathesis,  or  from  contamination  with  the 
products  of  incomplete  metabolism,  or  their  insufiicient  excretion 
— ^i.  e.,  disturbed  retrograde  metamorphosis.  Thus,  not  long  ago, 
Burney  Teo  *  claimed  that  one  of  the  prominent  manifestations  of 
this  condition  was  dyspepsia  in  all  its  forms.  Other  authors,  like 
Brinton,  Pavy,  etc.,  do  not  recognize  a  specific  gastric  disorder,  and 
may  therefore  be  considered  to  take  a  view  more  closely  allied  to 
our  own.  The  same  is  true  of  the  rheumatic  diathesis,  which  has 
played  quite  a  prominent  part  in  French  literature.  Although  I 
have  not  met  a  single  case  of  true  gout  with  coincident  gastric  dis- 
turbances, yet  I  have  seen  numerous  such  examples  in  chronic  artic- 
ular rheumatism,  in  which  they  were  so  marked  that  the  pains  in 
the  joints  were  comparatively  insignificant. 

Whether  there  is  any  close  connection  between  these  conditions 
I  shall  refrain  from  saying,  just  as  I  shall  do  in  the  similar  relations 
of  affections  of  the  skin  and  the  stomach,  to  which  Pidoux  ||  has  paid 
particular  attention.     Finally,  I  consider  that  there  is  a  much  better 

*  [Leube.     Mlinch.  med.  Wochenschr.,  1895,  No.  7. — Ed.] 
f  Rosenstein.     Berlin,  klin.  Wochenschr.,  1890,  No.  13. 

t  Edg.  Gans.    Ueber  das  Verhalten  der  Magenf  iinotionen  beim  Diabetes  mellitus 
IX,  Congress  fiir  innere  Medicin.     Vienna,  1890. 

*  Burney  Yeo.     On  the  Treatment  of  the  Gouty  Constitution.     British  Med. 
Journal,  January  7  and  14,  1888. 

Jl  Pidoux.     Rapport  d  I'herpetisme  et  des  dyspepsies.    Union  med.,  1886,  No.  1, 


THE   PRACTICAL  VALUE   OP  THE  CHEMICAL  METHODS.    577 

established  as  well  as  a  more  practical  connection  between  the  digest- 
ive disturbances  and  the  various  forms  of  malaria  (i.  e.,  the  manifest 
and  especially  the  latent  forms  of  intermittent  fever)  and  typhoid 
fever,  particularly  its  ambulant  variety. 

Malarial  poisoning  may  be  manifested  as  an  intermittent  car- 
dialgia  (Leube  *)  or  in  the  form  of  the  various  neuroses  of  the  stom- 
ach, which  will  be  characterized  by  a  certain  regularity  (Rosenthal, 
Glax  f ),  and  which,  according  to  the  latter  observer,  can  be  relieved 
only  by  quinine  as  long  as  the  patient  remains  in  the  malarial  dis- 
trict. Kisch  :{:  in  Marienbad,  and  Glax  in  Eohitsch  [an  alkaline 
saline  spring  in  Steiermark,  Austria],  both  observed  that  it  was 
most  striking  that,  after  the  use  of  the  waters  of  these  places,  the 
neuroses  first  occurred  in  true  intermitting  attacks  and  then  finally 
disappeared  altogether.  Formerly  I  not  infrequently  had  the  oppor- 
tunity of  treating  such  cases  of  marked  intermittent  dyspepsia. 
[These  various  manifestations  are  quite  common  in  ISTew  York,  and 
should  always  be  borne  in  mind  in  obstinate  cases.  The  routine  use 
of  the  thermometer  will  occasionally  aid  in  recognizing  these  cases. 
In  the  treatment,  Warburg's  tincture  will  be  found  to  be  especially 
useful.] 

Conclusion.— The  Practical  Value  of  the  Modern  Chemical  Tests. — 
In  the  course  of  this  book  I  have  always  brought  forward  the 
experiences  which  have  been-  gained  by  the  new  methods  of  investi- 
gation, especially  of  the  chemical  functions  of  the  diseased  stomach, 
and  I  have  thus  been  enabled  to  combine  the  old  well-known  noso- 
logical facts  with  the  diagnostic  and  therapeutic  results  recently 
gained.  The  task  still  remains  to  mention  what  place  is  occupied  by 
the  chemical  methods  of  investigation  in  the  individual  affections  of 
the  stomach,  and  how  far  they  warrant  drawing  absolute  conclu- 
sions upon  the  nature  of  the  disease  under  consideration.  Do  the 
stomach  and  the  test  tubes  enable  us  to  discover  specific,  character- 
istic functional  disturbances  which  belong  invariably  and  exclusively 

*  Leube.  Beitrage  zur  Diagnostik  der  Magenkrankheiten.  Deutsch,  Archiv, 
fiir  klin.  Med.,  Bd.  xxxiii. 

t  Glax.     Ueber  die  Neurosen  des  Magens.     Vienna,  1887,  S.  206. 
X  Log.  cit. 


578  DISEASES  OF  THE  STOMACH. 

to  an  individual  case,  and  thus  establisli  the  diagnosis  like  the 
presence  of  tubercle  bacilli  in  the  sputum  and  hyaline  casts  in  the 
urine  ?  Or,  are  they  simply  the  signs  of  a  more  general  significance 
which  have  nothing  to  do  with  a  specific  morbid  process  ?  It  is 
known  that  some  recent  authors  have  gone  so  far  as  to  classify  the 
diseases  of  the  stomach  into  those  with  an  increase,  diminution,  and 
absence  of  hydrochloric  acid,  and  possibly  some  may  regret  that  I 
"  have  not  followed  the  fashion  "  and  arranged  the  subject-matter 
from  this  standpoint.  I  have  as  remote  an  idea  of  doing  this  as  I 
would  have  of  writing  a  text-book  on  special  pathology  in  which 
the  diseases  are  classified  according  to  the  presence  or  absence  of 
dropsy,  jaundice,  albuminuria,  etc.  On  the  contrary,  if  we  wish  to 
adhere  to  facts  and  avoid  exaggerations,  our  present  knowledge  may 
be  summed  up  in  the  following  propositions : 

There  are  two  great  groups  of  results  in  the  chemical  examina- 
tions of  the  gastric  juice  which  differ  from  the  normal :  1.  The 
untimely  occurrence  of  organic  acids.  2.  The  changes  in  the  gas- 
tric juice  itself  (i.  e.,  the  secretion  of  hydrochloric  acid,  pepsin,  and 
rennet),  and  the  absorption  and  motility  of  the  organ. 

1.  The  occurrence  of  organic  acids,  especially  lactic  acid,  during  a 
stage  of  digestion  in  which  they  can  not  be  demonstrated  normally 
by  the  tests  already  known  to  you.  This  is  always  characteristic  of 
definite  pathological  conditions,  the  manifestations  of  which  are  also 
perceived  subjectively  by  the  patient.  These  acids  are  due  to  ab- 
normal processes  of  decomposition  or  fermentation,  whose  causes 
may  be  manifold  but  which  are  always  combined  with  a  morbid 
state,  provided  the  latter  expression  be  made  to  include  not  only  an 
abnormal  chemical  result,  but  also  more  or  less  well-marked  disturb- 
ances in  the  affected  individual.  This  explains  the  significance  of 
the  demonstration  of  lactic  and  the  fatty  acids,  J^ow,  since  these 
products  of  fermentation  are  always  associated  with  a  prolonged 
stay  of  the  ingesta  in  the  stomach,  and  usually  with  an  absolute 
or  relative  lessening  of  the  secretion  of  hydrochloric  acid,  a  diag- 
nosis may  be  ventured  in  this  direction  from  a  knowledge  of  these 
facts. 

2.  Much  more  complicated  are  the  conditions  concerning  the 
significance  of  changes  in  the  gastric  juice.     Since  the  secretion  of 


THE   PRACTICAL   VALUE   OP   THE   CIIEMICAL   METBODS.    579 

pepsin  and  rennet  ferments  goes  hand  in  hand  with  that  of  hy- 
drochloric acid — excepting  trifling  variations  which  have  no  prac- 
tical meaning — what  is  said  of  the  latter  may  serve  as  a  statement 
for  all. 

It  has  always  been  my  belief,  as  I  have  stated  in  the  earlier 
editions  of  this  book  that  increase  or  diminution  in  the  amount  of 
the  hydrochloric  acid  secretion  is  a  sign  which  is  related  to  the 
various  types  of  disease  only  in  so  far  that  some  tend  to  cause  its 
increase,  while  others  its  diminution  or  even  absence ;  but  this  de- 
pends entirely  upon  the  anatomical  or  functional  disturbances 
which  accompany  these  morbid  types.  ]!^aturally,  these  cause  the 
changes  in  the  production  of  hydrochloric  acid ;  hence  it  is  their 
extent  in  the  course  of  the  disease  which  will  determine  how  much 
the  secretion  of  acid  will  be  affected.  At  all  events,  we  may  say 
that  one  group  will  never  cause  an  increased  secretion  of  acid — i.  e., 
all  those  forms  in  which  an  extensive  organic  destruction  or  change 
in  the  secreting  parenchyma  has  taken  place.  So  far  as  we  know, 
there  is  no  vicarious  increase  in  the  activity  of  the  remaining  glan- 
dular cells.  This  group,  therefore,  includes  carcinoma,  chronic 
gastritis  and  its  sequelae,  atrophy  of  the  mucous  membrane,  mucous 
degeneration  of  the  gastric  glands ;  possibly,  also,  certain  chronic 
vascular  lesions — as,  e.  g.,  amyloid  degeneration  of  the  blood  vessels 
[of  the  stomach].  We  must  also  add  other  chronic  enfeebling 
morbid  processes  which  may  cause  the  disappearance  of  HCl, 
such  as  profound  anaemia,  tuberculosis,  cardiac  diseases,  dia- 
betes, etc. 

But,  if  we  reverse  this  statement,  and  say  that  certain  kinds  of 
disease  cause  an  increased  secretion,  we  would  be  going  too  far. 
An  increased  secretion  is  always  functional,  a  sign  of  irritation. 
But,  as  is  well  known,  every  such  overproduction  may  cause  exactly 
the  opposite  condition ;  I  refer  not  only  to  the  result  of  exhaustion 
following  overexcitation,  but  also  to  the  condition  of  depression 
from  the  very  beginning.  Thus  it  may  happen  that  we  some- 
times encounter  an  absence  of  hypersecretion  in  a  condition  which 
is  usually  accompanied  by  a  strong  stimulation  of  the  secreting  ele- 
ments, as  gastric  ulcer.  A  neurosis  may  manifest  itself  at  one  time 
by  an  overproduction  of  acid  during  the  period  of  digestion  (hyper- 


580  DISEASES  OF   THE  STOMACH. 

cMorliydria) ;  at  another  time  by  a  continuous  secretion  (hypersecre- 
tion). Other  cases  also  exist  in  which  there  is  such  a  diminution  in 
the  secretion  of  hydrochloric  acid  that  the  amount  is  permanently 
reduced  to  a  minimum. 

Undoubtedly,  the  normal  process  of  digestion  is  accompanied 
by  so  copious  a  secretion  of  hydrochloric  acid  that  not  alone  are 
various  combinations  formed  with  the  different  foods  present,  but 
there  is  also  a  certain  excess  of  free  acid  which  seems  to  be  indis- 
pensable for  the  completion  of  normal  gastric  digestion.  But  we 
must  not  forget,  as  I  showed  some  time  ago  in  the  digestion  of  albu- 
men,* and  as  has  since  been  corroborated  by  Salkowski,  Rosenheim, 
and  others,  that  peptonization,  even  though  it  is  slight,  may  take 
place  without  any  free  acid ;  that  normally,  as  in  menstruation,  no 
free  acid,  or  only  a  very  small  quantity,  is  secreted ;  and  that  the 
human  organism  manifestly  possesses  in  no  insignificant  degree  the 
capacity  of  compensating  for  an  absence  of  hydrochloric  acid,  pep- 
sin, and  rennet  by  driving  the  chyme  out  of  the  stomach  much 
sooner,  and  relegating  it  for  digestion  to  the  intestine. 

After  all  this  I  think  all  will  agree  with  me  if,  in  general,  I 
attribute  no  positive  diagnostic  value  to  the  simple  fact  that  the 
acidity  is  increased  or  diminished  or  apparently  normal,  provided 
this  is  referred  to  no  other  acids  than  free  hydrochloric  acid  ;  and 
if  I  consider  such  results  only  as  a  supplementary  although  very 
important  feature  in  completing  and  establishing  the  entire  clinical 
picture.  On  the  other  hand,  I  do  not  wish  to  be  misunderstood, 
and  I  therefore  say  emphatically  that  this  statement  is  in  no  way 
intended  to  detract  from  the  value  of  our  examinations;  on  the 
contrary,  they  are  indispensable  to  us,  and  in  all  cases  where  cir- 
cumstances will  not  permit  them  we  feel  in  doubt,  and  "  somewhat 
at  sea." 

At  every  step  in  the  preceding  discussions  it  will  have  been  ob- 
served the  proof  of  the  extent  to  which  our  knowledge  has  been 
extended  and  amplified  by  the  new  methods  of  investigation  ;  but, 
on  the  other  hand,  in  view  of  many  recent  events,  I  beheve  it  is  my 


*  C.  A.  Ewald.    Ueber  den  "  CoefBcient  de  partage  "  und  iiber  das  Vorkommen 
von  Milchsaure  und  Leucin  im  Magen.     Virchow's  Archiv,  Bd.  xc,  S.  349. 


THE   PRACTICAL  VALUE  OP   THE   CHEMICAL   METHODS.    581 

duty  to  warn  against  a  one-sided  overestimation  of  tlieir  value.  As 
I  have  already  stated  in  Chapter  I,  time  has  since  shown  the  cor- 
rectness of  mj  views.  We  have  gradually  sailed  into  smoother 
waters  ;  indeed,  a  reaction  has  already  set  in,  so  that  the  results  of 
the  chemical  examinations  are  even  valued  less  than  they  ought  to 
be.  This  negative  view  is  just  as  erroneous  as  the  one-sided  over- 
valuation of  these  methods.  Only  the  most  careful  and  thorough 
consideration  and  weighing  of  all  the  symptoms  which  can  be  ob- 
tained with  all  the  diagnostic  resources  will  enable  us  to  recognize 
the  existing  disease.  ISTot  even  the  most  careful  chemical  examina- 
tion of  the  functions  of  the  stomach  will  put  within  our  grasp  the 
divining-rod  which  will  magically  call  forth  the  fountain  of  knowl- 
edge from  the  adamantine  rocks  of  obscure  symptoms  !  Even  to- 
day the  old  saying  is  true  that — 

"  Ubi  ratio  sine  experimentis  mendax, 
Ita  experientia  sine  ratione  fallax." 


INDEX 


Abelous,  187. 
Abercrombie,  127,  403. 
Abscess  of  stomach,  181. 
Absorption  in  stomach,  60,  75,  455  ;  char- 
acter of,  75  ;  test  of,  75. 
Achlorhydria,  24, 26.    See  Hydrochloric 

Acid,  Absence  of. 
Achylia  gastrica,  205,  221. 
Acid,  acetic,  tests  for,  44. 
butyric,  tests  for,  44. 
hydrochloric.  See  Hydrochloric  Acid. 
lactic,  in  stomach  contents,  27,  29  ;  in 
cancer,  30,  351 ;  fermentation-,  41 ; 
meat-   41 :   quantitative   estimation 
cf,  54 ;  tests  for,  29,  30,  41,  44,  55 ; 
varieties  of,  41. 
salicyluric,  test  of,  in  urine,  79. 
sareolactie,  41. 
Acid  salts,  25  ;  quantitative  estimation  of, 

55  ;  tests  for,  34. 
Acidity  of  gastric  juice,  cause  of,  27 ; 
variations  of,  24,  580 ;  determination 
of,  24. 
of  stomach  contents,  25  ;  stages  of,  25 

testing  of,  30,  47. 
percentage  of,  34. 
total,  tests  for,  31. 
quantitative  determination  of,  46. 
Acids,   fatty,   in  stomach  contents,   44 ; 
tests  for,  44. 
free,  tests  for,  34. 
organic,  in  stomach,  44,  578  ;  tests  for, 

40. 
See  also  Contents  of  Stomach. 
Acoria.  517. 
Adamkiewicz,  320. 
Adenopathies  in  gastric  cancer,  329. 
Adler,  572. 
Agoraphobia  in  chronic  gastritis,  216. 

in  gastric  neuroses,  476. 
Air,  distention  of  stomach  with,  85,  87. 
Akerlund,  538. 
88 


Akinesis  of  stomach,  276. 
Alapy,  573. 
Albertoni,  375. 

Alberts,  J.  E.,  315,  317,  318,  320. 
Albu,  159. 

Albumen,  digestion  of,  60. 
disks,  65. 

putrefaction  of,  in  stomach,  288. 
reaction  on  aniline  dyes,  36. 
reactions  of,  60,  61. 
Albumoses,  60. 
Albutt,  261,  291. 

Alcohol  in  contents  of  stomach,  44. 
Alderson,  4. 

Alimentation,  rectal,  150,  434,  436. 
Alt,  500,  525. 

Anachlorhydria,  26,  518.     See  also  Hy- 
drochloric Acid,  Absence  of. 
Anacidity  of  gastric  juice,  24,  343,  579. 
nervous,  518. 

See  Hydrochloric  Acid,  Absence  of. 
Anadenia    of  stomach,   203,  217 ;  diag- 
nosis,  221 ;  from  cancer,   223 ;  lav- 
age in,  223  ;  pathology,  199  ;  relation 
to    pernicious     anaemia,    220,    563 ; 
stomach  contents  in,  222 ;  treatment, 
224. 
Anaemia,  condition  of  stomach  in,  570. 
pernicious,   condition   of   stomach   in, 
220,  563. 
Anaesthesia  of  skin  in  gastric  ulcer,  405. 

of  stomach,  517. 
Andeer,  233. 
Andral,  181,  276,  281,  317,  328,  417,  545, 

564. 
Aniline  dyes  in  stomach  analyses,  35. 

objections  to,  36. 
Anorexia,  484. 

in  cancer  of  stomach,  331. 
in  catarrh.  172. 
in  dilatation,  282. 
in  phlegmon,  183. 
583 


584 


DISEASES  OP  THE  STOMACH. 


Anorexia  in  tumors  of  kidney,  573. 

in  tuberculosis,  487,  564. 

in  ulcer  of  stomach,  403. 

nervous,  484. 
Antiperistaltic  unrest  of  stomach,  516. 
Antrum  pylori,  91. 
Apepsia,  192. 
Appetite,  470. 

in  gastric  cancer,  331. 

lack  of.     See  Anokesia. 

perverse,  483. 

ravenous,  482.     See  Bulimia. 
Ardor  ventriculi,  209. 
Aretfeus,  478. 
Arnold,  522. 
Arnott,  4. 
Asiatic  pills,  553. 
Asp,  216. 

Aspirator,  stomach,  12  ;  Boas's,  13. 
Asthenia  of  stomach,  276. 
Asthma,  dyspeptic,  215,  510. 
Atony  of  stomach,  192,  527. 

in  chronic  gastritis,  211, 

in  dilatation,  276. 
Atrophy  of  stomach.     See  Anadenia. 

of  muscularis  of  stomach,  203. 
Audhui,  262. 

Auerbach's  plexus.  453,  459. 
Aura  vertiginosa,  216. 
Autenrieth,  314. 

Autointoxication,  intestinal,  159. 
Autoseope,  Kirstein's,  125. 

Bacillus  coli  communis  in  stomach  con- 
tents, 46. 

Bacillus  gastricns,  185. 

Bacteria  in  acute  gastritis,  166. 
in  gastric  cancer,  75,  331,  333. 
in  gastric  phlegmon,  181. 
in  gastric  ulcer,  390. 

Bamberger,  255,  277,  345. 

Baraduc,  104. 

Barbacei,  401. 

Barbel,  320. 

Barlow,  401, 

Barnes,  117. 

Barras,  473,  478,  513. 

Barry,  Du,  284. 

Bartels,  220,  275. 

Basch,  Yon,  216, 

Bastianelli.  461. 

Battistini.  233. 

Baura,  305. 


Beatson,  161. 

Beau,  330,  473. 

Beaumont,  164,  240,  383. 

Beck,  413. 

Becker,  384. 

Behrens,  87. 

Belching,  nervous,  508. 

Belladonna  in  cancer  of  stomach,  370. 

Benecke,  560. 

Benedict,  102. 

Bennet,  446. 

Bernstein,  216,  566. 

Berrez,  115. 

Berthold,  393. 

Best,  376. 

Betz,  45,  288. 

Bial,  187,  353. 

Bianchi,  263, 

Bidder,  49,  53. 

Biedert,  57, 

Billroth,  306, 

Biernacki,  73,  573, 

Bile,  cause  of  chronic  gastritis,  208. 
in  stomach  contents,  73, 
taste  of,  172. 
test  for,  73. 

Binswanger,  556,  561. 

Birchner,  307. 

Bird,  Golding,  344,  347. 

Birsch-Hirschfeld.  393. 

Bismuth  in  gastric  ulcer,  439. 

Bitters,  229. 

Biuret  reaction,  60. 

Blaschko,  218,  530,  531. 

Blass,  31,  32. 

Blatin,  4. 

Blondeau,  216. 

Blood,  condition  of,  in  cancer  of  stom- 
ach, 336. 
condition  of,  in  ulcer  of  stomach,  385, 

407. 
in  stools,  408,  409,  411,  424. 
vomiting  of.     See  H^matemesis. 

Blume.  425. 

Boas,  7,  8,  13,  14. 18,  21,  28,  30,  32, 35, 38, 
39,  44,  45,  48,  63,  68,  69,  70,  75,  153, 
195,  196.  208,  213,  229,  239,  246,  261, 
267,  288,  290,  298,  333,  350,  351,  352, 
387,  442,  506,  507,  508,  515,  525,  546. 
reagent  of,  28. 

Bocci,  105. 

Boerhave,  318, 

Bollinger,  376.  , 


INDEX. 


586 


Butticher,  390. 

Bouchard,  159,  2G3,  294. 

Bouilleaud,  415. 

Bourdon,  564. 

Bourneville,  521,  522. 

Bouveret,  374, 293,  294,  295, 338, 506,  507. 

Bovis,  De,  192. 

Braam-Houckgeest,  278. 

Brautigain,  315. 

Bradypepsie,  192. 

Braun,  49,  229. 

Bramann,  Von,  807. 

Brieger,  233,  566,  567. 

Brinton,  112,  121,  181,  184,  195,  313,  318, 

321,  324,  328,  329,  330,  331,  340,  342, 

353,  391,  409,  576. 
Briquet,  478,  516,  537. 
Bristowe,  509. 
Brochet,  452. 
Brock,  106. 
Bromide-water,  552. 
Broussais,  192,  276,  493. 
Brown,  71,  492, 
Brown-Sequard,  178. 
Briick,  216. 
Briiggemann,  571. 
Brunner,  305. 
Brunton,  Lauder,  157,  173. 
Brush,  stomach,  4. 
Buch,  494,  495. 
Buezlygan,  570. 
Budd,  244,  400,  411,  413,  424,  426,  433, 

440,  473,  501,  545. 
Bukler,  183. 
Bulimia,  481 ;  etiology,  483 ;  forms,  484 ; 

occurrence,  482 ;  peristalsis  in,  484; 

treatment,  483,  548. 
Bull,  E.,  215. 
Bull,  W.  T.,  306. 
Bunge,  78,  160. 

Burettes,  forms  used  in  titration,  33. 
Burkart,  106,  494,  536,  556,  559. 
Bush,  F.,  4. 
Bussel,  376. 

Cachexia,  in  gastric  cancer,  334,  359. 

in  hysteria,  360. 
Cahn,  29,  49,  64,  65,  118,  180,  255,  271, 

280,  290,  291,  347,  349,  351. 
Calculi,  gastric,  480. 
Callow,  185. 
Camerer,  389. 
Camus-Corrignon,  205. 


Canstatt,  4. 

Cancer  of  stomach.     See  Carcinoma. 

Canula,  permanent,  of  ojsophagus,  143. 

Caragiosiadis,  105. 

Carbonic  acid  gas,  distention  of  stomach 

with,  85. 
Carcinoma  of  stomach,  313. 

bacteria  in,  75,  331,  833. 

blood  in,  336. 

course,  339. 

diagnosis,  343;  absence  of  hydrochlo- 
ric acid,  343 ;  cachexia  in,  359 ;  can- 
cerous tumor,  354;  from  atrophy, 
223 ;  lactic  acid  in,  30,  351 ;  pieces 
of  tissue  obtained  by  washing  out 
stomach,  352. 

differential  diagnosis,  361 ;  between 
gastric  ulcer  and  cancer,  331,  362, 
363,  418. 

etiology,  317. 

ferments  in,  350. 

localization,  323. 

lymphadenitis,  329. 

metabolism,  changes  in,  338. 

occurrence,  313  ;  age,  313 ;  duration, 
339;  heredity,  315;  locality,  314; 
primary  or  secondary,  327 ;  rela- 
tions to  gastric  ulcer,  318 ;  sex,  314. 

pathological  anatomy,  320;  varieties, 
321. 

perforation,  330. 

position  of  stomach  in,  334. 

prognosis,  339. 

propagation,  327. 

sarcinse,  absence  of,  334. 

shape  of  stomach  in,  325. 

site,  324 ;  sequelae  of,  325. 

symptoms,  330 ;  anorexia,  331 ;  bowels, 
343 ;  cachexia,  334 ;  pain,  331 ;  pres- 
ence of  tumor,  334 ;  tongue,  331 ; 
vomiting,  331,  332,  334;  vomiting 
of  blood,  331. 

thrombosis,  328. 

treatment,  366 ;  analgesics,  369 ;  con- 
durango,  366 ;  diet,  371 ;  mineral 
waters,  373;  of  constipation,  370; 
of  hfematemesis.  369 ;  of  A^omiting, 
368 ;  surgical,  373. 

tuberculosis  occurring  with,  328. 

ulceration,  329. 
Cardia,  cancer  of,  131, 153  ;  stomach  con- 
tents in,  153. 

closure  of,  460 ;  in  rumination,  524. 


586 


DISEASES   OP   THE  STOMACH. 


Cardia,  contraction  of,  spastic,  116. 

function  of,  460. 

neoplasms  of,  120  ;  cause  of,  121. 

paresis  of,  520. 

relaxation  of,  509,  520,  524. 

spasm  of,  116,  515. 

stenosis  of,  109. 

stricture  of,  109 ;  dilatation  of,  132 ; 
feeding  in,  149  ;  gastrostomy  in,  146 ; 
organic,  114;  pain  in,  116;  passage 
of  bougies  in,  124,  141 ;  symptoms, 
109;  treatment,  140. 
Cardialgia,  209,  487. 

in  gastric  cancer,  231. 

in  stricture  of  cardia,  116. 
Carlsbad  water,   action    of,   in    chronic 
gastritis,  250;  in  gastric  neuroses, 
561 ;  in  ulcer,  434,  435. 
Carron,  116. 

Carswell,  324,  328,  ^95,  424. 
Cartellieri,  509. 

Catarrh,  acute,   of    stomach,   163.     See 
Gtastritis,  Simple  Acute. 

subacute,  181. 

chionic,  192.     See  Gastritis,  Chronic 
Glandular. 
Catarrhus  atrophicus,  203. 
Cathelineau,  491. 
Chlapowski,  540. 
Chambers,  402,  478. 
Chantemasse,  391. 
Charcot,  490. 

Chemical  tests,  value  of,  577. 
Cherchewsky,  531. 
Cheron,  540. 
Chiaje,  Delia,  145. 
Chiari,  115,  206,  393. 
Chittenden,  60,  70,  232,  240. 
Chlorine.     See  Contents  of  Stomach. 
Chlorosis,  condition  of  stomach  in,  570. 

relation  to  gastroptosis,  571. 
Chomel.  193. 
Chovstek,  184,  417. 
Cimbali,  475. 
Cirrhosis  ventriculi,  195. 
Clapoleraent,  262. 
Cloquet,  314. 

Clostrydinm  butyricum,  161. 
Clozier,  276. 
Cohn.  28,  160,  161,  516. 
Cohnheim,  8,  155,  169,  180,  196,  200,  223, 

327,  352,  354,  399. 
Coin,  116. 


Cold-water  treatment,  108. 

Colgan,  394. 

Colleville,  573. 

Colloid  cancer  of  stomach,  321,  322,  823. 

Colic,  biliary,  430. 

stomach.  515. 
Coma  dyspepticum,  292. 

dyspnoeic,  336. 
Comby,  213,  282. 
Comparetti,  473. 
Concretiones  benzoartices,  480. 
Condurango  in  gastric  cancer,  866. 
Congo  red,  35. 
Contejean,  461. 
Contents  of  stomach,  6. 

acetic  acid  in,  44. 

acetone  in,  45. 

acidity  of,  36,  37,  47,  387,  406,  580. 

alcohol  in,  44. 

ammonia  in,  45. 

bacteria  in,  46,  75.     See  Bacteria. 

bile  in,  73. 

butyric  acid  in,  44. 

carbonic  acid  in,  45. 

chlorine,  estimation  of,  52. 

chlorides,  estimation  of,  52. 

examination  of,  24. 

fatty  acids  in,  44. 

filtration  of,  31. 

fungi  in,  185. 

in  acute  gastritis,  167. 

indol  in,  46. 

in  gastric  crises,  491. 

in  gastric  cancer,  343, 

in  gastric  catarrh,  221. 

in  gastric  dilatation,  283. 

in  gastric  ulcer,  387,  406,  422. 

in  mucous  gastritis,  222. 

intestinal  parasites  in,  187. 

lactic  acid  in,  44. 

larvfe  in,  181. 

marsh  gas  in,  45. 

methods  of  obtaining,  12. 

micro-organisms  in,  187.  See  Bacteria. 

microscopical  examination  of,  74. 

defiant  gas  in,  45. 

organic  acids  in,  44. 

pepsin  in,  66,  67,  226,  350. 

ptomaines  in,  45. 

reaction  of.  25. 

rennet  in,  67,  350. 

routine  examination  of,  56. 

sulphuretted  hydrogen  in,  45. 


INDEX. 


587 


Contents  of  stomach,  sugar  in,  73. 

taste  of,  172. 

while  fasting,  73. 
Contraction  of  stomach,  325. 
Cooper,  390. 
Copland,  192,  405,  501. 
Cordes,  216,  217,  251. 
Cordua,  44G. 
Cornil,  417. 
Cornillon,  422. 
Cough,  stomach,  214. 
Couteret,  193. 
Cramps  of  stomach,  477,  515 ;  in  gastric 

dilatation,  292. 
Cramer,  8,  440. 
Cravate  de  Suisse,  460. 
Crises,  gastric,  490,  535,  574. 
Crisp,  387. 
Cruveilhier,  181,  205,  269,  279,  380,  39G, 

400,  411,  436. 
Cuilleret,  540. 
Cullen,  209. 
Cure,  rest,  434,  556. 

Schroth's  dry,  299. 
Curling,  390. 
Cynorexia,  482. 

Da  Costa,  437. 
Daettwyler,  382. 
Daguet,  422. 
Daland,  337. 
Damaschino,  193. 

Danger  of  stomach  tube,  8,  127,  422. 
Darwin,  522. 
Dastre,  208. 
Dauber,  508. 
Daumann,  546. 
Debove,  424,  437. 
Decker,  525. 

Defecation  by  mouth,  516. 
Defailliance,  481. 

Degeneration,  colloid,  of  stomach,  279. 
Degeneration  of  nervous  plexuses  of  in- 
testines, 530. 
Deglutition  murmurs,  93. 

in  dilatation  of  stomach,  264. 

in  rumination,  524'. 
Dehio,  82,  88,  260,  524. 
Deininger,  184,  185. 
Deiters,  269. 
Dejerine,  491. 
Delamare,  490. 
Demange,  491. 


Depressive  neuroses  of  stomach,  474. 
Desnos,  516. 
Dettweiler,  567. 
Devic,  298,  294,  295. 
Dextrin,  70. 
varieties,  70. 
test  for,  71. 
Diabetes,  condition  of  stomach  in,  575. 
Diarrhoea  due  to  terror,  454. 
Diastase,  69 ;  taka  diastase,  227. 
Diemerbroeck,  290. 
Diet  in  gastric  cancer,  371. 
in  gastric  catarrh,  238. 
in  gastric  ulcer,  437. 
Dietrich,  123,  422. 
Dieulafoy,  402. 

Digestion  of  albumen,  60 ;  test  of,  65. 
of  starch  and  sugar,  60,  69. 
effect  of  alcohol  on,  232. 
in  absence  of  hydrochloric  acid,  162. 
reflex  disturbances  of,  544. 
test  in  gastric  neuroses,  530. 
Dilatation  of  oesophagus.  111.  132. 
Dilatation  of  stomach,  211,  254. 
atonic,  276. 
course  of,  296. 

diagnosis  of,  255,  295  ;  Boas's  method, 
261  ;  auscultation,  262  ;  Dehio's 
method,  260 ;  inspection,  255 ;  Leu- 
be's  method,  261 ;  measuring  capacity 
of  stomach  in,  264;  murmurs  of 
deglutition  in,  264 ;  palpation,  261 ; 
percussion,  258 ;  peristalsis  in,  256, 
257 ;  use  of  phonendoscope  in,  263 ; 
Rosenbach's  method  in,  264 ;  suc- 
cussion,  262. 
etiology,  266  ;  atony  of  stomach,  276  ; 
exclusion  of  limited  areas  of  muscu- 
lar fibres  of  stomach,  278 ;  feebleness 
of  motor  nerves,  277;  polyphagia, 
277  ;  stenoses  of  pylorus,  268 ;  wan- 
dering kidney,  275. 
occurrence,  280 ;  with  biliary  calculi, 

274. 
pathology,  279. 
physical  signs,  255. 
prognosis,  296. 

symptoms,  280  ;  acidity,  288  ;  chemical 
functions  of  stomach,  285 ;  coma, 
292;  constipation,  291;  delayed  ab- 
sorption, 289 ;  dryness  of  tissues, 
291;  fermentations,  277,  283,  286; 
inflammable  gases,  286;  peristalsis. 


588 


DISEASES   OP   THE   STOMACH. 


291  ;    sarcinae    and    bacteria,    283 ; 
stagnation  of  stomach  contents,  283 ; 
sulphuretted  hydrogen  in,  45 ;  teta- 
ny, 292;  urine,  state  of,  293,  294; 
vomit,  283  ;  vomiting,  282. 
treatment,  299 ;  dry  diet,  299 ;  resec- 
tion of  pylorus,  306  ;  use  of  cathar- 
tics, 301;  faradization,  305;  hydro- 
chloric acid,  300 ;  massage,  305  ;  size 
of  tube  for,   11 ;    strychnine,  301 ; 
washing  out  stomach,  302. 
Dimethylamidoazobenzo],  40. 
Diphtheritic  gastritis,  166,  180. 
Dirkler,  486. 
Dirksen,  93,  95. 

Distention  of  stomach,  with  air,  85,  87. 
with  carbonic-acid  gas,  85. 
with  water,  82,  87. 
Dittrich,  181,  317,  318,  327,  330,  339. 
Diverticula  of  oesophagus,  119. 
Douche,  Scotch,  305,  554. 

stomach,  99,  550. 
Dreschfeld,  345. 
Dronke,  438. 
Drozda,  417. 
Dubujadoux,  196. 
Ducasse,  523. 
Dujardin  Beaumetz,  193,  194,  225,  263, 

292,  301,  339. 
Dunglison,  405. 

Duodenum,  ulcer  of,  390,  430,  432. 
Duplay,  262,  301. 
Dupuytren,  390. 
Duzan,  313. 
Dyspepsia,  156. 
asthenique,  276. 
atonic,  192. 
buccal,  72. 
cardiaca,  215. 
flatulent,  532. 
habitual,  192. 
in  gastric  cancer,  331, 
in  gastric  dilatation,  282, 
in  stricture  of  cardia,  110. 
irritable,  192. 
nervous,  529. 

peristalsis  of  stomach  in,  162. 
reflex,  530,  546. 
salivary,  72. 
uterina,  546. 

Also  see  Gastritis,  Chronic  Catar- 
rhal. 
Dyspnoeic  coma  in  gastric  cancer,  336, 


Dyspeptic  asthma,  215,  510. 

Eating,  slow,  238. 

repugnance  toward,  484, 

Ebstein,  86,  169,  188,  205,  381,  526, 
527. 

Edleffsen,  214, 

Edinger,  16,  18,  169,  179,  386,  566. 

Egeberg,  146. 

Eiehenberg,  242. 

Einhorn,  16,  23,  40,  82,  96,  97,  98,  102, 
103,  106,  134,  196,  205,  218,  220,  221, 
525,  550. 

Eisenlohr,  204,  218,  337. 

Eisenhardt,  402. 

Electrization  of  stomach,  102,  305. 
effect  on  muscular  fiber,  104. 
effect  of,  105. 

Electrode,  stomach,  103. 

Elixir  peptogene,  225. 

EUenberger,  70, 

Ely,  327. 

Emminghaus,  9,  45,  288, 

Emptiness  of  stomach,  481. 

Engel,  417. 

Enemata  in  chronic  gastritis,  206. 

Enemata,  nutritive,  150,  151,  436. 

Enteroliths  after  bismuth,  441. 

Enteroptosis,  539. 
treatment  of,  555. 

Eppinger,  401. 

Epstein,  14. 

Eras,  115. 

Erichsen,  390. 

Ergot,  in  hsematemesis,  369,  444. 

Erlmeyer,  552. 

Erosions  of  stomach,  196 ;  htemorrhagic, 
335. 

Eructation,  foul-smelling,  286. 
hysterical,  508. 
nervous,  508. 

Escherich,  211. 

Etat  mammelone,  280. 

Ether,  extraction  of  stomach  contents 
with,  42. 

Euehlorhydria,  27. 

Everett,  551. 

Ewald,  C.  A.,  5,  7,  8,  14,  21,  28,  32,  37, 
54,  58,  60,  63,  65.  70,  72,  73,  77,  78, 
79,  93,  94,  111,  116,  150,  152,  158, 
161,  162,  169,  178,  190,  195,  220,  225, 
226.  229,  240,  246,  253,  278,  286,  288, 
320,  321,  345,  346,  358,  371,  382,  386, 


INDEX. 


589 


387,  406,  425,  438,  450,  4G3,  463,  517, 
519,  528,  532,  539,  546  573,  580. 

Ewald,  R.,  448. 

Expression,  Ewald's  method  of,  13. 
contraindications  to,  15. 

Eyeselein,  316. 

Faber,  75,  415. 

Fabriciiis  ab  Aquapendente,  4,  531. 

Fagge,  Hilton,  291. 

Falk,  160. 

Falkenheira,  284. 

Fames  canina,  483. 

Fauvel,  417. 

Favus  of  stomach,  185. 

Fawizky,  49. 

Feeding  by  rectum,  150,  151,  436. 

Fenwick,  S.,  199,  204,  220,  304,  418,  473, 

486,  487,  533. 
Fenwick,  W.  S.,  15,  169,  179,  402,  563, 

564,  569,  570. 
Ferber,  259. 
Fereol,  540. 
Fermaud,  187. 
Fermentation  (alkaline)  of  albuminoids 

in  stomach,  311,  388. 
in  stomach,  167,  335,  399. 
lactic  acid,  41. 
Ferrarini,  406. 
Fiedler,  393. 
Finkler,  327. 
Finny,  411. 
Fischl,  321. 

Fistula  of  stomach,  making  of,  146. 
Fistulas  after  perforation  of  gastric  ulcer, 

416. 
Flatow,  319. 
Fleiner,  348,  373,  393,  304,  309,  440,  441, 

544. 
Fleischer,  43,  546. 
Flint,  320. 
Food,  taking  of,  471. 

refusal  of,  484. 
Foote,  394,  413,  414,  446. 
Forster.  434. 
Fothergill,  473. 
Fouquet,  516. 
Fox,  Wilson,  314,  387,  434. 
Frank,  523. 
Frankel,  E.,  186. 

Frerichs,  von,  4,  85,  137,  384,  417,  561. 
Freud,  534. 
Freund,  199. 


Freyhan,  535. 

Friedenwald,  31,  40,  44,  58,  69,  353. 

Friedheim,  51. 

Friedreich,  339,  366. 

Fries,  410. 

Full  stomach,  477. 

Fungus  htBmatodes  of  stomach,  331,  333. 

Fiirstner,  106. 

Fungi  in  stomach  contents,  385. 

Gaertig,  123. 
Galliard,  402,  417,  429. 
Gallois,  523. 

Ganglion  cells  of  stomach,  453. 
Gans,  576. 
Garland,  435,  475. 
Gastralgia,  310. 
genuine,  488. 
hysterical,  497. 

diagnosis  from  ulcer  and  cancer,  418. 
differential  diagnosis  between  gastral- 
gia due  to  ulcer  and  colics,  430. 
in  diseases  of  central  nervous  system, 

490. 
in  gastric  cancer,  331. 
in  gastric  ulcer,  403,  404. 
in  gastric  neurasthenia,  493. 
in  nervous  dyspepsia,  537. 
in  psychoses,  499. 
reflex,  544. 

treatment  of,  369,  443,  548,  549. 
Gastrectasis.     See  Dilatation  of  Stom- 
ach. 
Gastric  crises,  490,  535,  574. 
Gastric  fever,  173. 
Gastric  juice.     See  Juice,  Gastric. 
Gastric  neurasthenia,  539. 
Gastrite  hyperpeptique,  506. 
Gastritis  acida,  195. 

Gastritis,  simple  acute,  165 ;  glandular, 
165  ;  idiopathic,  165  ;  sympathetic, 
178 :  acidity  in  sympathetic,  179. 
diagnosis,  174;  etiology,  165;  fatty 
acids  in,  167,  173 ;  fermentation  in, 
167 ;  hydrochloric  acid  in,  173  ;  lac- 
tic acid  in,  167,  173 ;  micro-organ- 
isms in,  166;  occurrence,  165;  pa- 
thology, 168 :  psychical  factor  in,  166 ; 
stomach  contents  in,  167;  symptoms, 
171;  treatment,  176;  varieties,  173. 
chronic  glandular,  192;  agoraphobia 
in,  816;  anadenia  in,  see  Anadenia; 
antifermentatives  in,  237,  335 ;  ano- 


590 


DISEASES   OF   THE  STOMACH. 


dynes  in,  244;   atrophy  of  mucous 
membrane  in,  199 ;  bitters  in,  229 ; 
bromelin  in,  227;    constipation  in, 
213  ;    course,   224  ;    diagnosis,  221 ; 
diet  in,  238 ;  drugs  in,  233,  234 ;  dys- 
peptic asthma  in,  215 ;  electricity  in, 
229 ;  enemata  in,  247 ;  etiology,  206 ; 
■  hydriatic  treatment  of,  237 ;  exfolia- 
tion of  mucous  membrane  in,  8, 196 ; 
hydrochloric  acid  in,  221,  225,  235  ; 
hygiene  in,  243 ;  lavage  in,  200,  227 ; 
mineral  waters  in,  249 ;  minute  anat- 
omy of,  197 ;  orexin  in,  232 ;  papoid 
in,  227 ;  pancreatin  in,  227 ;  pathol- 
ogy of,  195 ;   pepsin  in,  226 ;  prog- 
nosis of,  224 ;  pulse  in,  215 ;  purga- 
tives  in,   245 ;    stomach    cough   in, 
214 ;  symptoms,  208 ;  synonyms,  192 ; 
tongue  in,  209  ;  treatment,  224 ;  urine 
in,  214 ;  varieties,  200 ;  vertigo  in, 
216 ;  vomiting  in,  210. 
diphtheritic,  166,  180. 
emphysematous,  186. 
membranous,  166,  180. 
mucous,  208,  222 ;  lavage  in,  222. 
mycotic,  185. 
parasitic,  185. 
parenchymatous,  169. 
piirulenta     phlegmonosa,    181 ;    diag- 
nosis, 184 ;  etiology,  181 ;  occurrence. 
181 ;  pathology,  182;  symptoms,  183; 
treatment,  185 ;  varieties,  181. 
toxic,  188 ;  diagnosis,  189 ;  symptoms, 
189 ;  treatment,  189. 
Gastroadenitis,  164. 
Gastrodiaphane,  96, 
Gastrodynia,  487. 
Gastroenterite,  192. 
Gastrograph,  82. 
Gastroliths,  376. 
Gastromalacia,  389. 
Gastroptosis,  89,  539. 
treatment  of,  555. 
Gastroseope,  95. 
Gastroseopy,  95. 
Gastrostomy,  146. 
feeding  after,  152. 
technique  of,  148. 
Gastrosuceorrhoea,  24,  502. 

mucosa,  508. 
Gastroxynsis,  507. 
Gavarett,  328. 
Geigel,  31,  33. 


Gempt,  Te,  437. 

Georges,  231. 

Gerhardt,  187,   330,  392,  396,  406,  409, 

431,  432,  441. 
Germont,  336. 
Gersung,  144. 
Gigglberger,  240. 
Gilles-Sabourin,  401. 
Girandeau,  262. 
Glaser,  184. 

Glax,  181,  255,  516,  577. 
Glenard,  539,  540,  543,  555. 

disease  of.     See  Gastroptosis. 
Gluczinsky,  345,  346,  406,  570. 
Gmelin,  18,  73. 
Goldschmidt,  108. 
Goldstein,  417. 
Goltz,  455,  462. 
Gombault,  196. 
Goodhart,  554. 
Goodsir,  284. 

Gothard  Tunnel  disease,  548. 
Gout,  condition  of  stomach  in,  576. 
Graf,  316. 
Graham,  425. 
Grande,  79. 
Grasset,  339. 
Graves,  210. 
Griesinger,  314. 
Griess,  392. 
GrifRni,  381,  399. 
Grote,  227,  442. 
Griinfeldt.  393. 
Griitzner,  229. 
Grundzach,  162,  274. 
Grusdew,  566. 
Giinsburg,  389. 
Giinzburg,  17,  38. 

reagent,  38. 
Guipon,  483. 
Guiteras,  115. 
Gull,  490. 
Gumlich,  63,  371. 
Gussraann,  174. 
Guttmann,  233. 
Gyromele,  Turck's,  4,  236. 

Haafewinkel,  227. 
Habershon,  181,  396,  400. 
Haberlin,  75,  314,  316,  319,  327,  337. 
Hacker,  Yon,  115,  306. 
Hsematemesis.  407,  423. 
causes  of,  424. 


INDEX. 


591 


Haematemesis,   diagnosis   from   ho3mop- 
tysis,  433. 

in  cardiac  diseases,  424. 

in  cholera,  426. 

in  direct  traumatism,  428. 

in  diseased  gastric  blood-vessels,  428. 

in  epilepsy,  424. 

in  fever,  intermittent,  426. 

in  fevers,  exanthematous,  426. 

in  gastric  ulcer,  407. 

in  gastritis  glandularis  chronica,  426. 

in  helminthiasis,  426. 

in  hysteria,  426. 

in  liver,  acute  yellow  atrophy  of,  424. ' 

in  liver,  cirrhosis  of,  424. 

in  miliary  aneurism,  429. 

in  oesophageal  varis,  425. 

in  progressive  ansemia,  428. 

in  purpura  hcTemorrhagica,  426. 

in  scurvy,  426. 

parenchymatous,  427. 

treatment  of,  in  cancer,  369 ;  in  gen- 
eral, 429  ;  in  ulcer,  443. 
Haemoptysis,  423. 
Hafner,  428. 

Hahn,  306,  307,  374.  375. 
Hair  tumors  in  stomach,  376,  480. 
Hall,  415. 
Haller,  465. 
Hamburger,  160,  161. 
Hammerschlag,  67,  200,  352. 
Hampeln,  335. 
Hanot,  121,  196. 
Hansemann,  320. 
Hanssen,  515. 
Hart,  Ed.,  33. 
Hart,  Wheatley,  133. 
Hartung,  337. 
Hasselmann,  114. 
Hauser,  317,  319,  320,  399. 
Hayem,  27,  49,  169,  194,  196,  204,  208, 

250,  506,  570. 
Heart,  condition  of  stomach  in  diseases 

of,  571. 
Heart-burn,  209,  510. 
Heberden,  225. 
Heddaeus,  119. 
Helmer,  49. 

Heidenhain,  170,  395,  454. 
Heilbrun,  428. 
Heinecke.  306,  308. 
Heintz,  181. 
Heitler,  319. 


Ilellwig,  306,  307. 

Hemialbumose,  60. 

Hem  meter,  7,  82. 

Henle,  395. 

Henne,  232. 

Henoch,  175,  215,  329,  343,  393,  428,  510. 

Henry,  564. 

Heredity  of  cancer,  315. 

Heron,  71. 

Herpes  labialis  in  acute  catarrhal  gas- 
tritis, 172. 

Herschell,  163. 

Heryng,  96. 

Herzen,  225. 

Heynsius,  287. 

Hildebrand,  187,  566,  568. 

Hiller,  417. 

Hilton,  446. 

Hippocrates,  478. 

Hirseh,  29,  389,  406. 

Hirschberg,  550. 

Hirschfeld,  28. 

Hirschspring,  269. 

Hoesslin,  von,  35. 

Hoffmann,  F.  A.,  49,  50,  51, 164, 165,  209. 

Hofmeister,  70,  528. 

Hollevoet,  412. 

Holmes,  390. 

Hood,  291,  409,  428. 

Hoppe-Seyler,  58,  178,  287. 

Honigmann,  501,  506. 

Hornbaum,  495. 

Huber,  80,  151. 

Hubert,  306. 

Hiibner,  406,  501. 

Hiifier,  572. 

Hiippe,  286. 

Hufeland  366. 

Hughes,  446. 

Hugounang,  231. 

Hunger,  465. 
causes  of,  465. 
center  of,  466,  471. 

feeling  of,  466 ;  deviations  from,  481 ; 
inhibition  of,  468 ;  localization,  467 ; 
voracious,  481. 

Hunter,  4,  387,  390. 

Hutchinson,  564,  567. 

Hydrochloric  acid,  absence  of,  in  Addi- 
son's disease,  346 ;  in  amyloid  de- 
generation of  gastric  mucosa,  346 ; 
in  anadenia,  222:  in  fever,  179;  in 
gastric  cancer,  345 ;  in  gastric  neuro- 


592 


DISEASES  OP  THE  STOMACH. 


ses,  346;  in  menstruation,  546;  in 
mucous  catarrh  of  stomach,  346 ; 
permanent,  in  healthy  persons,  579  ; 
in  puhnonary  phthisis,  346,  567 ;  in 
valvular  diseases,  346. 

antiseptic  action  of,  160. 

free  and  combined,  25,  26,  47. 

free,  estimation  of,  47. 

influenced  by  electricity,  105. 

in  fever,  179 ;  in  phthisis,  566. 

loosely  combined,   method    of   deter- 
mining, 49. 

percentage  of,  24,  31. 

permanent  lessening  in   gastric  neu- 
roses, 580. 

relation  to  acidity  of  urine,  162. 

relation  to  indican  in  urine,  163. 

secretion  of,  25,  27. 

tests  for,  36,  37,  47. 

use  of,  221,  225,  235,  300. 
Hydi'ops  in  gastric  cancer,  336. 
Hydrotherapy,  108,  554. 
Hyperacidity,  24,  27,  194,  501,  502. 

in  gastric  ulcer,  387,  406. 

in  nervous  disorders,  502. 

occurrence,  502. 

test  of,  36. 

treatment,  507. 
Hyperfesthesia  of  stomach,  477. 

after  chloroform  narcosis,  479. 
Hyperchlorhydria.     See  Hyperacidity, 
Hyperkinesis,  16,  517. 
Hyperorexia,  482. 
Hypersecretion  of  gastric  juice,  501,  502. 

diagnosis,  505. 

forms  of,  502. 

in  cerebral  disorders,  545. 

periodical,  502. 

symptoms  of,  505. 
Hypersecretio  acida.  24,  501,  502. 
Hypochlorhydria,  27. 
Hypochondria,  483. 
Hysteria,  365,  477,  487,  492,  497. 

Idiosyncrasy  of  stomach,  480. 
Immermann,  220,  367,  368,  566,  567. 
Indigestion,  192. 
Innervation  of  stomach,  448. 
Insufficiency  of  stomach,  254.     See    Py- 
lorus and  Cardia  ;  see  Dilatation. 
Invert  sugar,  69. 
Iodoform  reaction,  Lieben's,  44. 
Intestines,  disturbed  digestion  of,  531. 


Intestines,  electrization  of,  105. 

haemorrhage  in,  408,  411,  424. 

in  diseases  of  stomach,  157. 

tympanites  of,  527. 

vicarious  action  of,  77,  351,  218,  580. 
Irritative  gastric  neuroses,  474,  477. 
Israel,  324. 

Jacobson,  97,  98. 
Jaksch,  von,  29,  45,  391,  392. 
Jaccoud,  516. 

Jaworski,  22,  24,  67,  78,  194,  223,  223, 
225,  226,  229,  237,  250,  265,  298,  308, 
321,  345,  387,  388,  399,  406,  435,  501, 
502,  503,  504,  505,  506,  567. 
Johannessen,  521. 
John,  70. 
Johnson,  68,  478. 
Jolles,  49. 
Jolly,  502. 
Jones,  A.,  105. 
Jones,  H.,  424,  564. 
Jong,  De,  30,  58,  352. 
Juice,  gastric,  acidity  of,  19,  24. 

acidity  while  fasting,  20. 

changes  in,  signifl.cance  of,  578. 

flow  of,  501 ;  continual,  503  ,•  in  cere- 
bral affection,  545  ;  periodical,  502. 

hyperacidity  of,  501,  502. 

hypersecretion  of,  501,  503. 

in  gastric  catarrh,  221. 

in  gastric  cancer,  343. 

in  gastric  dilatation,  285. 

in  gastric  ulcer,  387,  406. 

in  rumination,  525. 

parasecretion,  502. 

secretion  of,  19,  24. 
Julien,  114,  417. 
Jung,  De,  44. 

Jurgens,  218,  453,  454,  580. 
Jiirgensen,  299,  508,  525. 

Kabrehl,  160. 
Kaczarowski,  238. 
Kahlden,  196. 
Kahler,  37,  38,  491. 
Kahn,  345. 
Kalmus,  180. 
Kast,  189. 

Katzenellenbogen,  324,  329. 
Kaufmann,  J.,  75,  82,  ^61,  187. 
Kaufmann,  W.,  333. 
Keen,  446. 


INDEX. 


593 


Kelling,  93,  98,  120. 

Kellog,  74,  404. 

Kelynack,  319. 

Kering,  259. 

Key-Aberg,  304. 

Kidney,  condition  of  stomach  in  dis- 
eases of,  564,  572. 

Kietz,  345. 

Kinnicutt.  19,  30G. 

Kisch,  546,  577. 

Kitagawa,  537. 

Klebs,  159,  185,  417. 

Kleinert,  33. 

Kieist,  246. 

Klcmperer,  G.,  22,  68,  81,  119,  123,  179, 
231,  298,  338,  352,  566,  567. 

Klinkert,  204. 

Kobert,  462. 

Koch,  382. 

Kocher,  148,  374. 

KoUmar,  319,  420. 

Konig,  21. 

Korte,  390. 

Kooyker,  376. 

Korner,  118,  120,  523. 

Korczynski.  194,  298,  321,  388,  399,  406. 

Kornfeld,  16. 

Kossel,  547. 

Kossler,  50,  51.  53. 

Kraus,  32,  345. 

Kretschy,  546. 

Krishaber,  143. 

Kronecker.  93,  115. 

Kronfeld,  232. 

Kronlein,  374. 

Krukenberg,  37,  345.  490. 

Kriiger,  375, 

Kuhn,  287,  301. 

Kulcke,  319. 

Kulnefe,  46,  159. 

Kumagawa,  65. 

Kundmann,  4. 

Kundrat,  185,  213, 

Kunze,  375. 

Kupffer,  197. 

Kuttner,  7,  96,  97,  98,  265,  275,  555, 

Kussmaul,  4,  106,  150,  248,  254,  263,  271, 
280,  283,  291,  292,  294.  302,  303,  343, 
515,  516,  526,  529,  550. 

Knhne,  63. 

Kiister,  445. 

Laache,  336,  407. 


Labastide,  225, 

Lab-enzyme,  68. 

Lab-ferment,  67, 

Lab-zyraogen,  08.     See  Rennet. 

Labastide,  225. 

Laboulbene,  189. 

Lactic  acid.     See  Acid,  Lactic. 

Laenggries,  316. 

Laker,  264,  337. 

LambI,  537. 

Lanceraux,  417. 

Landau,  276. 

Landerer,  269. 

Landouzi,  491. 

Lang,  417. 

Lange,  327,  328,  397,  446. 

Langebach,  162. 

Langerhans,  395,  396,  397. 

Langermann,  51,  57. 

Langguth,  30,  55,  352. 

Laprevotte,  292. 

Large  stomach,  255. 

Laubenheimer,  338. 

Lauenstein,  306. 

Lavage  of  stomach,  98,  200,  227,  302. 
dangers  of,  304. 

Lebert,  165,  172,  173,  183,  193,  279,  313, 
316,  318,  324,  327,  329,  331,  339,  340, 
342,  353,  373,  391,  392. 

Ledoux-Lebard,  314. 

Leichtenstern,  133,  253,  264,  337,  407. 

Lemaitre,  205. 

Lenhartz,  275. 

Leo,  14,  19,  25,  29,  49,  50,  51,  54,  55,  56. 
67,  68,  437,  484,  517. 

Lepine,  329,  336. 

Lesser,  189. 

Lesshaft,  117. 

Letulle,  390,  391,  428. 

Leube,  3,  4,  5,  8,  9,  22,  69,  77,  80, 106, 150, 
168,  184,  246.  261,  275,  356,  384,  421, 
422,  433,  434,  435,  439,  441,  473,  529, 
530,  533,  535,  536,  550,  567,  572,  577. 

Leucin,  reaction  of,  28. 

Leudet,  417. 

Leury,  199. 

Leva,  525. 

Lewin,  W.,  183,  184. 

Lewy,  318. 

Leyden,  143,  491,  514,  532,  535,  556,  567. 

Liehtheim,  219. 

Lieberraeister,  283,  300,  567. 

Liebreich,  438,  537,  553. 


594 


DISEASES  OP   THE  STOMACH. 


Lienteric  stools,  186,  250. 

Lindeman,  183. 

Lippmaii,  33. 

Lisehe,  169. 

Litmus-paper,  22. 

Litten,  220,  275,  298,  401,  418,  425. 

Liver,  action  on  peptones,  158. 

■  condition  of  stomach  in  diseases  of, 
574. 

relation  of  diseases  of  stomach,  157. 
Lorenz,  45. 
Loreta.  295,  306. 
Loewenthal,  23,  225. 
Loffler,  160. 
Losch,  169. 
Louis,  564. 
Low,  390. 
Loye,  105. 
Lublinski,  114,  187. 
Lucke,  306. 
Lugol's  solution,  71. 
Lung,  haemorrhage  from,  428. 
Luschka,  110. 
Luton,  324. 
Liittke,  14,  28,  29,  30,  31,  47,  49,  50,  51, 

54,  58. 
Lymphadenoma  of  stomach,  323. 
Lyon,  26. 

Macfadyen,  161,  187. 

Mackenzie,  111,  141,  148,  147,  244. 

Macleod,  183. 

MacNaught,  210,  287. 

Magendie,  462. 

Maier,  269. 

Malaria,  condition  of  stomach  in,  577. 

Malbranc,  208,  275,  550. 

Malibran,  382. 

Maltose,  71. 

Malvoz,  375. 

Maly,  406. 

Manges,  99,  234,  333,  352. 

Marcet,  384. 

Marcone,  230. 

Marfan,  169,  402,  565. 

Marten,  395. 

Martin,  6,  186,  804,  391. 

Martin,  St.,  153. 

Martins,  14,  20,  28,  29,  30,  31,  47,  49,  50, 

54,  98. 
Massage  of  stomach,  108, 
Matthieu,   81,   163,  378,   299,   321,  437, 

504. 


Matthes,  440. 

Maydl,  413. 

May  em,  180. 

Mayer,  216. 

Mazotti,  113. 

McNaught,  161. 

Meat-juice,  300. 

Meat  peptone,  399 ;  chocolate,  800. 

Kemmerich's,  399.  „ 

Koch's,  399. 

solution,  Leube's,  114. 
Medullary  carcinoma  of  stomach,  331, 

333. 
Megalostria,  254. 

Meinert,  86,  98,  540,  542,  544,  571. 
Meissner's  plexus,  453,  459. 
Melfena,  424. 
Melsenemesis,  332. 

Melanotic  carcinoma  of  stomach,  323. 
Meltzer,  76,  94,  107,  115,  117,  413. 
Meltzing,  98,  571. 
Menasse,  376. 
Menassein,  169,  178. 
Menche,  333. 
Mendel,  332. 
Mendelsohn,  243. 
Mering,  von,  29,  49,  71,  76,  289,  345,  349, 

351. 
Merycismus,  521. 
Meschede,  187. 
Methyl  violet,  85. 
Mey,  882,  836. 
Meyer,  A.,  48,  51. 
Meyer,  C,  318. 
Meyer,'  E.,  125. 

Meyer,  G.,  169,  200,  203,  318,  553. 
Meyer,  John,  188,  184. 
Meyer,  R.,  280. 
Meyer,  W.,  148,  368. 
Meyerhof,  114. 
Michaelis,  445. 
Middeldorf,  416. 
Mikulicz,  95,  306,  308,  445. 
Milk  diet,  241. 

peptonized,  299,  371. 
Millard,  436. 
Miller,  160,  161,  387. 
Mineral  springs,  treatment  at. 

in  gastric  cancer,  373. 

in  gastric  catarrh,  349. 

in  gastric  neuroses,  561. 

in  gastric  ulcer,  446. 
Mineral  waters  in  gastric  neuroses,  553. 


INDEX. 


595 


Minkowski,  160,  274,  277,  293,  303,  355, 

445. 
Mintz,  47,  48,  54,  58,  184,  309. 
Miquel,  160,  387. 
Mislowitzer,  330. 
Mitan,  243. 
Mitchell,  J.  M.,  559. 
Mitchell,  Weir,  324,  425,  556,  559. 
Mobius,  531. 
Models  of  stomach,  91. 
Mohr,  33,  37. 
Montegre,  523. 
Moritz,  76,  107. 
Mosetig-Moorhof,  368. 
Motility,     60.       See     Movements     of 

Stomach. 
Mouisset,  337. 
Movements  of  stomach,  77,  459. 

in  bulimia,  484. 

in  chronic  catarrhal  gastritis,  212. 

tests  of,  78,  81. 
Mucous  gastritis,  208,  222. 
Mucous  glands  of  stomach,  171. 
Mucous  membrane  of  stomach,  atrophy 
of,  199,  563. 

degeneration  of,  granular,  199. 

fungi  of,  185. 

ha?morrhage  in,  395. 

polypi  of,  205. 

structure  of,  163. 

vacuoles  in  cells  of,  199. 
Mucus,  excessive  secretion  of,  508. 
Miiller,  Fr..  123,  292,  293,  338,  355,  385, 

407,  413. 
Muller,  Joh.,  449. 
Murchison,  343,  416,  417. 
Murmur,  deglutition,  93.  264,  525. 

absence  of,  95. 

aids  to  diagnosis,  93. 

gurgling,  118. 

nature  of,  93. 

press,  93. 

splash,  262. 

squirt,  93. 

succussion,  262. 
Muscularis  of  stomach,  atrophy  of,  203, 
279. 

feebleness  of,  276. 

hypertrophy  of,  279. 

paresis  of,  218. 
Muselier,  335. 
Musser,  401.  418. 
Iilyalgia  of  abdominal  muscles,  478. 


Natanson,  93. 

Naunyn,  214,  277,  303. 

Nausea,  477. 

Nauwerck,  186,  273. 

Nencki,  78. 

Neptune's  girdle,  514,  551. 

Nerves  of  stomach,  451. 

Nervous  system,  condition  of  stomach  in 

diseases  of,  574. 
Neschaieff,  153. 
Neumann,  114,  402. 
Neurasthenia,  492. 

irritative,  492. 

depressive,  493, 

gastric,  529. 

gastro-intestinal,  532. 

vago-sympathetic,  532. 
Neuroses  of  stomach,  448,  473. 

conditions  of  depression  in,  474,  517. 

conditions  of  irritation,  474,  477. 

classification  of,  474. 

etiology,  475. 

mixed  form,  474,  529. 

occurrence,  475. 

reflex,  474,  544. 

relations  to  other  neuroses,  474. 

treatment,  477,  548. 
Nicaladoni,  133. 
Niemeyer,  216. 
Nolte,"392,  397. 

Noorden,  Von,  162,  372,  491,  501,  502. 
Normal  soda  solution,  33. 
Nothnagel,  32,  203,  814,  220,  275,  537. 

Obalinski,  308. 
Obrastzow,  88,  89. 
Oddi,  208. 
Odier,  439. 

Esophageal  sound,  125. 
(Esophageal  tube,  127. 
CEsophagoscope,  124. 
CEsophagus,  cancer  of,  118,  120. 

symptoms,  123,  124. 
CEsophagus,  dilatation  of,  111,  132. 

diverticula  of,  119. 

neoplasms  of,  118.  120. 

permanent  canula  of,  143. 

sounding  of,  125. 

stenosis  of,  109. 

stricture,  cicatricial,  111;  feeding  in, 
149 ;  gastrostomy  in,  146 ;  rectal 
feeding  in,  150. 

spasmodic,  116. 


596 


DISEASES  OP  THE  STOMACH. 


CEsophagus,    ulcer    of,    corrosion,   115 ; 

syphilitic,  111 ;  tubercular,  113. 
Oettinger,  292. 
Oil  test,  81. 

Openchowski,  Von,  394,  463. 
Oppenheim,  491. 
Oppenheimer,  337,  407,  433. 
Oppler,  67,  75,  284,  333,  334,  352. 
I'orange  Poirier,  34. 
Oresin,  232. 

Organic  acids.    See^  Acids. 
Ord,441. 

Orth,  185,  186,  195. 
Oser,  5,  86,  87,  229,  266,  275,  299,  367, 

412,  436,  461,  473,  474,  478,  488,  492, 

498,  551. 
Osgood,  366. 
Osier,  86,  220,  257,  258.  262,  291,  356, 

425,  564. 
Ost,  265. 

Ostersprey,  337,  407. 
Osswald,  570. 

Ott,  342,  356,  358,  364,  540,  544. 
Overloading  of  stomach,  168. 

Pacanowski,  88. 

Pain,  epigastralgie,  537. 

epigastric,  478. 

in  cancer,  331,  359,  364. 

in  catarrh  of  stomach,   febrile,   172 ; 
chronic,  210. 

in  hyperesthesia  of  stomach,  478. 

in  hypersecretion  of  gastric  juice,  505. 

in  hysterical  gastralgia,  497. 

in  nervous  dyspepsia,  536. 

in  neurasthenic  gastralgia.  493. 

in  stricture  of  the  cardia,  116. 

in  ulcer  of  stomach,  404. 
Palpation  of  stomach,  83. 

of  pancreas,  84,  90. 

of  stomach  tube,  261. 
Parasecretion,  24,  502. 
Pariser,  98,  353,  416. 
Parsons,  446. 
Pauli,  263,  281. 
Pavy,  386,  482,  576. 
Peiper,  567. 

Pemberton,  225,  435,  478,  501. 
Penzoldt,  43,  45,  75,  87,  232,  240,  263, 

290,  303. 
Pepper,  106. 

Pepsin  and  hydrochloric  acid,  digestion 
by,  65. 


Pepsin  and  hydrochloric  acid,  in  chronic 
catarrhal  gastritis,  226. 

quantitative  estimation  of,  67. 
Pepsinogen,  67,  233. 
Peptone,  60. 

action  of  liver  on,  158. 

artificial,  371. 

chocolate,  371. 

enema,  150. 

pastilles^  Ma^gi's,  299. 

reactions  of,  60,  61. 
Peptonuria  in  gastric  dilatation,  394. 
Perforation  in  gastric  cancer,   330 ;  in 

gastric  ulcer,  413. 
Perforation  peritonitis,  414. 
Peristalsis  of  stomach,  77,  459. 
Pertik,  269. 
Peyer,  482,  548. 
Pfeifeer,  229,  250. 
Pfungen,  Von,  212,  437,  528,  529. 
Phenolphthallein,  32,  33. 
Phlegmon,  gastric.   See  Gastritis  phleg- 

MONOSA. 

Phloroglucin-vanillin  test,  38. 

Phonendoscope,  263,  358. 

Phthisis  ventriculi.     See  Anadenia. 

Pick,  412,  570. 

Pidoux,  576. 

Pinel,  479. 

Piorry,  87. 

Pitt,  323,  390. 

Playfair,  556. 

Pneumatosis,  510. 

Points,  painful,  Burkart's,  494,  536. 

Poirier,  I'orange,  34. 

Poensgen,  213,  526. 

Poisoning,  188. 
with  alcohol,  188  ;  caustic  alkalies,  188, 
189  ;  hydrochloric  acid,   188 ;  nitro- 
benzol,  188  ;  oxalic  acid,  310  ;  phos- 
phorus, 188  ;  sulphuric  acid,  188. 

Poisson,  411. 

Poltowicz,  541. 

Polyphagia,  517. 

Polypi  of  stomach,  205. 

Polypoid  cancer  of  stomach,  331,  322. 

Pomper,  187. 

PopofP,  387. 

Portal,  283. 

Position,  vertical,  of  stomach,  90. 

Potton,  482. 

Powell,  411. 

Power,  117. 


INDEX. 


597 


Pradazzi,  88,  89. 

Prazmowski,  161. 

Pribram,  95,  216. 

Probefruhstiick.     See  Test  Breakfast. 

Probemahlzeit.     See  Test  Meal. 

Probemittagbrod.     See  Test  Dinner. 

Proenzyme,  rennet,  68. 

Propeptone,  60. 

reactions  of,  61. 

relations  of  to  digestion,  62. 
Proteolysis,  65, 
Ptyalin,  69. 

quantitative  examination  of,  72. 
Ptyalism,  reflex,  547. 
Pump,  stomach,  4,  5,  12. 
Puncta  dolorosa.     See  Points,  Painful. 
Purgative,  Oydtinann's,  248. 
Purgatives,  245. 

Pylorus,  cancer  of.     See  Carcinoma  of 
Stomach. 

appearance  of,  in  neoplasms,  95. 

closure  of,  460. 

functions  of,  460. 

hypertrophy  of  muscularis  at,  357,  362. 

incontinence  of,  526. 

palpation  of,  262. 

relaxation  of,  520. 

spasm  of,  515. 

spastic  contraction  of,  278. 

stenosis  of,  cicatricial,  268  ;  congenital, 
269  ;  hypertrophic,  269  ;  mechanical, 
269 ;  causes  of  stenosis,  external  to 
stomach,  274. 
Pyrosis,  209,  510. 

Quenu,  565. 

Quincke,  93,  115,  130,  220,  294,  382,  406. 

Ramm,  230. 
Rampold,  343. 
Rankin,  442. 
Raoult,  540. 
Raudnitz,  68. 
Rawzier,  338. 
Ray,  446. 

Reaction,  ethyldiacetic  acid  (in  urine), 
293.     (For  other  reactions  see  under 
individual  headings.) 
Reagent,  Boas's,  38,  39. 

Griinzburg's.  38. 

Lieben's,  44. 

Nessler's,  44. 

Topfer's,  40,  48. 


Reagent,  Uffelmann's,  41. 

source  of  errors,  42. 
Reale,  79. 

Recklinghausen,  Von,  180. 
Reckmann,  433. 
Reed,  17. 

Reflex  dyspepsia,  530,  546. 
Reflexes  from  other  organs  on  the  stom- 
ach, 544. 
Regnard,  105. 
Regurgitation,  520. 

in  diverticula  of  oesophagus,  521. 

in  stricture  of  oesophagus  and  cardia, 

111. 
Reichmann,  24,  96,  229,  236,  501,  502, 

504,  505,  506,  507. 
Reinert,  407. 
Relations,  mutual,  of  stomach,  liver,  and 

intestines,  155 ;  and  nervous  system, 

574  ;  other  organs,  563. 
Renal  colic,  430. 

Rennet  ferment,  67;   quantitative    test 
for,   69  ;    proenzyme,   68  ;     zymogen, 

68. 
Reimer,  426. 
Reinhard,  356. 
Renvers,  143. 
Reoch,  37,  38. 
Resorcin,  234 ;  test,  39. 
Rest  cure,  Leube-Ziemssen,  in  ulcer,  434. 

Weir  Mitchell,  556. 
Retzius,  367. 
Rheumatism,  condition  of  stomach   in, 

576. 
Richet,  152,  453,  458. 
Richter,  284,  333,  494,  535. 
Riegel,  22,  24,  26,  32,  74,  82,  86,  98,  107, 

153,  161,  208,  255,  258,  286,  333,  345, 

352,  387,  388,  389,  406,  421,  501,  503, 

504,  505,  506. 
Rieger.  102. 
Riess,  366,  367,  552. 
Ritter,  29,  389,  406. 
Roberts,  232,  235,  239. 
Rockwitz,  375. 
Rolleston,  120. 
Rokitanski,  114,  121,  181,  274,  383,  389, 

390,  396. 
Rosch,  375. 
Rose,  262. 

Rommelaere,  3.38,  339. 
Rosenbaeh.  85,  212,  215,  254,  255,  264, 

282,  345,  528,  548,  549. 


598 


DISEASES   OF   THE  STOMACH. 


Rosenheim,  7,  8, 19,  29,  45,  59,  95,  96,  99, 
120,  124,  142,  185,  195,  220,  267,  309, 
319,  321,  333,  345.  347,  349,  352,  374, 
387,  391,  406,  422,  440,  551,  580. 

Rosenstein,  516,  576. 

Rosenthal,  150,  473,  474,  483,  490,  492, 
494,  509,  514,  550,  552,  566,  568,  577. 

Rosenthal,  C,  68. 

Rosin,  18. 

Ross,  192. 

Rossbach,  507. 

Rossier,  523,  525. 

Roth,  316,  382. 

Rothschild,  406. 

Rowing  in  chronic  catarrhal  gastritis, 
243. 

Ructus.    See  Eructation. 

Riihle,  567. 

Rumination,  521. 

Rumpel,  189. 

Rumsaeus,  4. 

Runebei'g,  86. 

Range,  525. 

Rupture  of  stomach,  189. 

Ruppstein,  286,  287. 

Rutherford,  247. 

Rydygier,  308. 

Sabel,  115. 
Saccharifieation,  69. 

by  saliva,  70. 
Sachs,  169,  171,  199,  425,  429. 
Sadler,  337. 
Sahli,  17,  76. 
Salkowski,  65,  235,  580. 
Salol  test,  78. 
Saly,  501. 
Samuelson,  386. 
Sanarelli,  320. 
Sanctuary,  273. 
Sansoni,  50. 

Sarcinfe  ventriculi,  284,  334. 
Sarcoma  ventriculi,  323,  375. 
Sasaki,  218,  530,  531. 
Sassezky,  178. 
Satiation,  feeling  of,  469. 

lack  of,  484. 
Saundby,  554. 
Sauvage,  526. 
Savelieff,  45,  440,  441. 
Sawyer,  553. 
Scheperlen,  220. 
Scherf,  417. 


Schetty,  179,  566. 
Scheuerlen,  320. 
Schonborn,  376. 
Schiff,  225,  381,  452,  467,  528. 
Schill,  320. 
Schillbach,  105. 

Schirrous  cancer  of  stomach,  321,  324. 
Schlesinger,  72,  333. 
Schliep,  8. 
Schlosing,  54. 

Schluckgerausch.     See  Murmur,  Deglu- 
tition. 
Schmauss,  408. 
Size  of  stomach,  88. 
Situation  of  stomach,  88. 
Schmidt,  F.,  49.  53, 173,  200. 
Schmidt-Miihlheim,  290,  457. 
Schmidtmann,  478,  521. 
Schmilinsky,  261,  262. 
Schneider,  337,  521,  522. 
Schnetter,  85. 
Schneyer,  337. 
Schrader,  466. 

Schreiber,  18,  19,  142,  506. 

Schroth's  dry  diet,  299. 

Schuchardt,  318. 

Schule,  20,  352. 

Schultze,  161,  287. 

Schutz,  6,  87,  275,  516,  528. 

Schwalbe,  169. 

Scirrhus  of  stomach,  321,  324. 

Secretion  of  stomach,  453. 

Sedgwick,  393. 

Sedillot,  147. 

See,  Germain,  22,  193,  237,  239,  244,  263, 
278,  294,  422,  443. 

Seemann.  37,  49. 

Seglas,  521,  522. 

Sehrwald,  386. 

Senator,  45,  142,  159,  187,  288. 

Senn,  265,  308. 

Sensibility  of  the  stomach,  463  :  morbid, 
478. 

Sere,  De,  526. 

Shape  of  stomach,  changes  in,  91. 

Sialorrhoea,  547. 

Sieber,  160. 

Siebert,  244. 

Sievers,  78,  79,  80,  106,  525. 

Siewecke,  362. 

Silbermann,  382. 

Silberstein,  80. 

Silberti,  233. 


INDEX. 


599 


Silver  nitrate,  271. 

Simon,  163. 

Simple  gastritis,  165. 

Singer,  38,  524. 

Siphon,  stomach,  4. 

Siphonage  in  washing  out  stomach,  98. 

Siredey,  335. 

Sjoqvist,  49.  57. 

Skin,  aniesthesia  of,  in  gastric  ulcer,  405. 

hypera^sthesia  of,  in  gastric  ulcer,  405. 

condition  of  stomach  in  diseases  of,  576. 
Skjelderup,  301. 
Skoda,  173. 
Smirnow,  166,  180. 
Smith,  A.,  274. 
Snow,  316. 

Soda  solution,  normal,  33. 
Sodium  chloride,  reaction  of,  36. 
Sohlern,  Von,  392,  393. 
Sollier,  464. 
Sommerville,  4. 
Sonnenberg,  143. 
Sounding  of  stomach,  10. 
Sounds,  oesophageal,  5. 

siphon,  5. 

stomach,  5. 
Spallanzani,  16,  18,  160. 
Spath,  16. 
Spitzer;  34,  64. 
Splanchnoptosis,  542. 
Spray,  gastric,  102. 

Springs,  mineral,  treatment  at,  in  gastric 
cancer,  373  ;  catarrh,  249  ;  neuroses, 
561 ;  ulcer,  446. 
Stabchen  plessimeter  percussion,  264. 
Starch,  digestion  of,  60,  69. 

test  for,  71. 
Starck,  392. 
Status  gastricus,  192. 
Stein,  79. 
Stekhoven,  229. 
Stepp,  443. 
Stern,  313,  572. 
Stewart,  D.  D.,  31,  223,  352. 
Stewart,  Grainger,  183. 
Steyerthal,  479. 
Sticker,  73,  406. 
Stintzing.  29. 
Stienon,  319,  349. 
Stiller,  473,  476,  509,  529. 
Stintzig,  169. 
Stohr,  199. 
Stoll,  403. 
39 


Stockton,  104,  106. 

Storck,  366. 

Stomach,  anadenia  of.     See  Anadenia. 

atony  of.     See  Atony. 

atrophy  of.     See  Atrophy. 

capacity  of,  91 ;  to  determine,  92. 

carcinoma  of.     See  Carcinoma. 

catarrh  of.    See  Gastritis  catarrha- 

LIS. 

contents  of.    See  Contents  of  Stom- 
ach. 
dilatation    of.      See    Dilatation    of 

Stomach. 
distention  with  air  or  carbonic  acid,  85. 
haemorrhage  in.     See  H^matemfsis. 
inflammation  of,  purulent.     See  Gas- 
tritis PHLEGMONOSA.    Inflammation 
of,  toxic.    See  Gastritis,  Toxic. 
innervation  of,  448. 
large,  255. 

measurements  of,  89. 
models  of,  91. 

motility  of.     See  Movements  of  Stom- 
ach. 
mucous  membrane.   See  Mucous  Mem- 
brane. 
'  neuroses  of.      See  iSTeuroses  of  Stom- 
ach. 
physical  examination  of,  82. 
phthisis  of.     See  AnadeniA. 
relation  to  liver  and  intestines,  155. 
secretion  in,  19. 
shape  of,  91. 
size  of,  90 ;  test,  82,  85. 
topography  of,  88. 
ulcer  of.     See  Ulcer  of  Stomach. 
Stools,  in   gastric  cancer,  343 ;  catarrh, 
213  ;  dilatation,  291 ;  dyspepsia  ner- 
vosa,   537  ;    phlegmon,   184 ;    ulcer, 
408. 
in  stricture  of  eardia,  113. 
lienteric,  343,  413. 
tarry,  408. 
Storer,  362. 
Strauss,  40,  43,  45,  46,  161,  187,  287,  288, 

333,  352. 
Stroh,  162. 
Striimpell,  264. 
Struve,  414. 
Subacidity,  24. 
Sugar,  digestion  of.  69. 
Suggestion  in  neuroses,  561. 
Superacidity,  24. 


600 


DISEASES  OF  THE  STOMACH. 


Surgery  of  storaaeh,  157,  373,  446.    See 

individual  diseases. 
Swieton,  Van,  318. 
Switzer,  143. 
Symonds,  143. 

Sympathetic  nerve,  course  of,  453. 
Syntonin,  demonstration  and  reactions 
of,  60. 

Tabes,  gastric  crises  in,  490,  535,  501. 
Talamon-Balzer,  401. 
Talma,  210,  381,  385,  388,  504,  553. 
Tantini,  462. 

Taste  in  gastric  cancer,  331 ;  ulcer,  403 ; 
gastritis  catarrhalis  chronica,   209 ; 
in  rumination,  522. 
Tawizki,  230. 
Teeth,  care  of,  in  diseases  of  stomach, 

238. 
Telangiectatic    carcinoma    of    stomach, 

321,  322. 
Terray,  230. 
Test  breakfast,  21. 
of  Ewald  and  Boas,  31. 
of  Klemperer,  22. 
dinner,  of  Leube,  22. 
raeal,  31. 
of  Riegel.  26. 
supper,  82.  398. 
Tetany    after     washing    out    stomach, 
304. 
in  gastric  dilatation,  292. 
ptomaines  in,  46. 
Thayer,  352. 
Thiersch,  319,  345. 
Thoman,  182. 
Thomas,  339,  560. 
Thompson,  242. 

Thrombosis  in  gastric  cancer,  328, 
Tiedemann,  18. 
Tilger.  375. 

Titration,  method  of,  30,  32. 
Todd,  193,  276,  478,  501. 
Topfer,  40,  48,  57. 
Tongue  in  diseases  of  stomach,  174. 
in  nervous  anorexia,  485. 
in  gastric  cancer,   331,  364 ;    catarrh, 
acute,  175;  chronic,  209;  dilatation, 
282  ;  hypersecretion  of  gastric  juice, 
505  ;  neurasthenia,   531 ;  ulcer,  364, 
403, 418 ;  phlegmonous  gastritis,  183 ; 
stricture  of  cardia,  113. 
Torminse  ventriculi,  515. 


Transformation  of  gastric  ulcer  into  can- 
cer, 422. 
of  starch,  60,  69. 

Trastour,  540. 

Traube,  277,  405. 

Treheux,  168. 

Trendelenburg,  153. 

Treves,  556. 

Trier,  433. 

Trinkler,  504. 

Troisier,  339. 

Tropaeolin,  34. 

Trousseau,  216,  248,  292,  373,  473,  501. 

Tsclielzoff,  344. 

Tschelzow,  339. 

Tschlenoff,  67. 

Tube,  Faucher's,  5. 
oesophageal,  5. 

stomach,  3;  dangers  of,  8,  137,  433; 
care  of,  7;  introduction  of,  9,  10, 11, 
13;  recurrent,  7;  sterilization  of,  7; 
obstruction  to  passage  of,  10  ;  length 
of,  11 ;  use  of,  in  children,  14 ;  in 
chronic  gastritis,  200,  227 ;  neuroses, 
550  ;  ulcer,  422  ;  tympanites,  510. 

Tuberculosis,   condition  of  stomach  in, 
564. 

Tuckwell,  513. 

Tiingel,  324. 

Tumor  in  gastric  cancer,  334. 
hypertrophy  5f  muscularis  at  pylorus, 

"357,  363. 
mediastinal,  118. 
retroperitoneal,  118. 

Tumors,  non-earcinomatous,  of  stomach, 
375. 

Turck.,  4,  46,  75,  101,  104,  307,  336,  238. 

Tympanites,  510. 

Typhoid  fever,  condition  of  stomach  in, 
564. 

Uffelmann,  29,  30,  40. 
Ulcer  of  duodenum,  390,  430,  433. 
Ulcer  of  stomach,  follicular,  383 ;  round, 
377. 

adhesions  in,  400. 

age  in,  393. 

anatomical  characters  of,  394. 

base,  396. 

bloody  stools  in,  408. 

bowels,  403. 

cicatrization  of,  399,  416. 

composition  of  blood  in,  385,  407. 


INDEX. 


601 


Ulcer  of  stomach,  corrosion  of   vessels 
in.  400. 

diagnosis  of,  418. 

differential  diagnosis,  418,  430. 

diet  in,  437. 

emaciation,  404. 

etiology,  380. 

excision  of,  446. 

fever  in,  404. 

fistulje  after,  416. 

form,  396. 

haemorrhage  in,  407. 
treatment  of,  443. 

hyperacidity  of  gastric  juice  in,  387, 
406. 

in  cutaneous  burns.  390. 

micro-organisms  in,  390. 

microscopic  appeai'ance,  898. 

necrosis,  400. 

occurrence,  391. 

operative  procedures  in,  446. 

pain  in,  403,  404. 
treatment  of,  443. 

pathological  anatomy,  394. 

perforation  of,  413. 

perforation  peritonitis,  414;    treat- 
ment, 415. 

prognosis,  433. 

relapsing,  388. 

rest  cure  in,  434. 

results  of,  399. 

sex,  393. 

site,  397,  431. 

size,  396. 

skin  in,  405. 

symptoms  of,  403. 

syphilitic,  402,  417. 

tongue  in,  403,  418. 

treatment  of,  434  ;  at  mineral  springs, 
446 ;  rectal  feeding  in,  434,  436  ;  use 
of  Carlsbader  water  in,  434,  435  ;  use 
of  iron  in,  437  ;  use  of  nitrate  of  sil- 
ver in,  442. 

tube  in,  422. 

tubercular,  401,  418. 

urine  in,  406. 
Unrest  of  stomach,  antiperistaltic,  516. 

peristaltic,  291.  515. 

Vagus,  coiirse  of,  451. 
Value  of  chemical  tests,  577. 
Vanillin,  phloroglucin,  38. 
Vanni,  385. 


Vaso-motor  nerves  of  stomach,  457 ;  re- 
lations of,  in  gastric  secretion,  457. 
Vassale,  381,  399. 
Velden,  Von  den,  70,  208,  343,  345,  347, 

387,  501,  504. 
Verneuil,  152. 
Vertigo  gyrosa,  216. 

stomachalis,  216. 

e  stomacho  laeso,  216. 
Villous  carcinoma  of  stomach,  322. 
Violet,  methyl,  35. 
Virehow,  R.,  114,  121,  169,  188,  328,  329, 

358,  396,  417,  543. 
Vizioli,  550. 
Voelkel,  425. 
Vogel,  366,  406. 
Voigt,  120. 
Volhard,  51,  53. 
Vormagen,  111. 
Vomit,  coffee-grounds,  333. 

taste  of,  172,  537. 
Vomiting,  462. 

faecal,  516. 

hysterical,  518. 

in  abscess  of  liver,  545. 

in  diseases  of  brain,  545 ;  spinal  cord, 
545. 

in  gastric  cancer,  331,  334;  catarrh, 
acute,  172 ;  chronic,  210 ;  in  gastric 
crises,  490;  dilatation,  282;  ulcer, 
407. 

in  hyperaesthesia  of  stomach,  479. 

in  hypersecretion,  505. 

in  injui'ies  to  uterus,  546. 

in  neurasthenia,  513,  537. 

in  operations  on  bladder,  546 ;  urethra, 
546. 

in  stricture  of  cardia,  72. 

in  phlegmonous  gastritis,  183. 

in  phthisis,  564. 

in  poisoning,  189. 

in  pregnancy,  545. 

in  renal  abscess,  545 ;  colic,  545 ;  dis- 
eases, 573. 

in  seasickness,  545. 

nervous,  511. 

of  blood.     See  H^matemesis. 

periodical,  514. 

reflex,  544. 

Waetzhold.  347. 

Wagner,  51. 

Waldeyer,  125,  319,  320,  321. 


602 


DISEASES  OF   THE  STOMACH. 


Walshe,  313,  317,  418. 

Walton,  250. 

Washing  of  stomach,  98. 

in  poisoning,  190. 
Water,  filling  stomach  with,  82,  87, 
Watson,  426. 
Wegele,  104, 

Weighing,  systematic,  559. 
Weill,  208. 
Weinert,  517. 

Weir,  307,  394,  413,  414,  446. 
Weiss,  4,  426. 
Weissgerber,  508,  509. 
Welch,  313,  314,  322,  325,  329,  836, 

392,  397,  412,  413,  429. 
Werner,  285,  575. 
Wesener,  160. 
West,  412. 
Westphal,  216,  491. 
Westphalen,  169,  203,  204,  255,  508. 
Widal,  391. 
Wiederhofer,  213,  281. 
Wiesner,  8. 
Wild,  236. 
Wilkens,  503. 
Wikinson,  313. 
Wilks,  390. 
Williams,  403. 
Willigk,  433. 


875, 


Wilson,  425. 
Windthier,  523. 
Winkhaus,  295. 
Winter,  27,  49. 
Winternitz,  305. 
Wirbelweh,  494. 
Witosowski,  398. 
Witte,  409. 
Wolff,  J.,  575. 
Wolff,  L.,  77,  162,  801. 
Wolfram,  346. 
Wolffler,  374. 
Wotitzky,  80. 
Wright,  73. 

Yeast  cells  in  stomach  contents,  187. 

Yellowly,  424. 

Yeo,  Burney,  242,  576. 

Zabludowski,  305. 

Zawadski,  45. 

Zeekendorf,  527. 

Zenker,  93,  94,  111    • 

Zesas,  147. 

Ziegler,  181,  376. 

Ziemssen,  Von,  8,  85,  105,  106,  111,  434, 

Zipkin,  573. 

Zweifel,  75. 

Zymogen.    See  Pepsin  and  Rennet. 


THE   END. 


PRACTICAL  DIETETICS, 

WITH  SPECIAL  REFERENCE  TO  DIET  IX  DISEASE. 
By  W.    oilman   THOMPSON,  M.  D., 

Professor  of  Materia  Medica,  Therapeutics,  and  Clinical  Medicine  in  the  University  of  the  City  of 
New  York  ;  Visiting  Physician  to  the  Presbyterian  and  Bellevne  Hospitals,  New  York. 

LARGE  OCTAVO,  EIGHT  HUNDRED  PAGES,   ILLUSTRATED. 

Cloth,  $5.00  ;  sheep,  $6.00. 

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"  This  book  strikes  us  as  a  very  important  contribution  to  medical  literature. 
We  are  greatly  mistaken  if  it  does  not  meet  with  a  very  large  sale.  All  classes  of 
practitioners  will  find  it  of  the  greatest  practical  value  to  them  in  their  daily  work." 
—Pacific  Medical  Journcd. 

"  This  is  at  once  the  best  and  most  exhaustive  book  upon  this  subject  with  which 
we  are  familiar.  The  best,  because,  in  the  first  place,  it  is  written  by  a  teacher  of 
therapeutics  who  knows  the  needs  of  the  practicing  physician,  and  yet  who  has 
taught  in  previous  years  as  a  professor  of  physiology  all  that  one  needs  to  know  in 
regard  to  the  principles  of  digestion  and  assimilation.  For  this  reason  the  author 
is  unusually  well  qualified  to  prepare  a  useful  manual,  but  it  is  not  nntil  one  has 
perused  the  volume  that  he  thoroughly  grasps  the  scope  and  depth  of  the  manner 
in  which  Dr.  Thompson  has  treated  his  subject." — Therapeutic  Gazette. 

"  Without  any  exception  we  believe  this  work  to  be  one  of  the  best,  if  not  the 
best,  for  practical  usefulness  that  has  issued  from  any  press  by  any  author  in  the 
last  ten  years.  It  is  particularly  useful  because  it  supplies  a  vacancy  in  the  library 
which  every  physician  finds  whenever  he  has  a  case  to  treat,  and  where  diet  occupies 
a  part  in  the  treatment  and  the  recuperation  of  the  patient.  ...  It  is  complete  in 
every  department,  each  chapter  being  a  model  of  conciseness  and  perfectness.  With 
a  book  like  this  at  hand,  many  a  day's  sickness  will  be  prevented  by  the  attending 
physician  being  able  to  prescribe  a  proper  diet." — Medical  Current. 


D.  APPLETON  AND   COMPANY,   NEW  YORK. 


REFERENCE-BOOK  OF 
PRACTICAL  THERAPEUTICS. 

BY  VARIOUS  AUTHORS. 
Edited  by  FRANK  P.  FOSTER,  M.  D., 

Editor  of  "  The  Neiv  York  Medical  JournaV  and  of 
Foster^s  "  Uncyclopcedic  Medical  Dictionary.'''' 


In  two  large  8vo  Tolumes.     Sold  only  l)y  sul)Scription. 

This  work  is  intended  as  a  ready-reference  book,  in  which  the 
physician  can  find  the  most  recent  information  concerning  the  uses 
and  application  of  remedies  ;  their  indications  and  counter-indica- 
tions ;  the  various  conditions  in  which  they  are  indicated  ;  the  forms  in 
which,  drugs  are  best  used,  their  doses,  and  the  methods  of  adminis- 
tration. 

"  It  is  essentially  a  book  for  the  practitioner,  and  is  an  up-to-date  work  of  refer- 
ence. Only  so  much  of  the  physiological  properties  of  drugs,  their  chemical,  miner- 
alogieal,  botanical,  and  zoological  relations  as  are  of  direct  bearing  on  their  use  in 
practice  have  been  considered  in  the  compilation  of  this  work.  .  .  .  The  ambitious 
physician  will  be  pleased  with  this  work." — Canadian  Medical  Record. 

"With  the  second  vohime  this  excellent  work  is  completed,  and  is  rendered 
immediately  available,  by  means  of  the  general  index  and  index  of  diseases  and 
remedies,  as  a  book  of  therapeutic  reference.  A  supplement  of  nearly  fifty  pages 
bears  witness  to  the  rapid  strides  in  medical  science,  since  it  is  filled  chiefly  with 
matter  relating  to  knowledge  acquired  since  the  appearance  of  the  first  volume. 
The  work  is  well  printed  and  well  bound,  and  the  brief  articles  on  every  subject 
relating  to  the  treatment  of  disease  are  excellently  written,  and  in  the  main  satis- 
factory as  to  the  information  they  impart." — Medical  Record. 

"  A  careful  review  of  the  second  volume  of  this  valuable  work  shows  that  there 
is  nothing  to  criticise,  and  that  the  same  care  has  been  exercised  by  the  various 
authors  in  their  contributions  that  characterized  those  in  the  first  volume.  The 
editor  has  executed  his  difficult  task  well,  and  has  added  all  the  information 
that  has  been  published  in  the  journals  on  the  different  subjects  since  the  original 
articles  were  written.  So  great  has  been  the  advance  in  therapeutics  that  it  has 
been  necessary  to  add  an  appendix,  thus  making  the  book  thoroughly  up  to  date  in 
3very  particular," — Medical  Sentinel. 


D.  APPLETON  AND  COMPANY,  NEW  YORK. 


A  TEEATI8E 

01^   DISEASES   OF   THE 

EECTUM,  ANUS,  a^d 

SIGMOID  FLEXURE. 


By  JOSEPH  M.  MATHE WS,  M.  D., 

OF   LOUISVILLE,    KY., 
PROFESSOE   OF   THE   PeINCIPLES   AND   PeAOTICE   OF   SuRGEEY,  AND    ClINICAL  LeOTCBEB 

ON  Diseases  of  the  Rectum,  in  the  Kentucky 
School  of  Medicine,  etc. 


With  Six  Chromolithographs  and  numerous  Illustrations  in  the  Text. 
SECOND  EDITION,   REVISED. 

8vo,  537  pages.     Cloth  binding,  $5.00. 


SOLD   ONLY  BY  SUBSCRTPTION. 


"  The  author  has?  placed  before  the  profession  the  fruits  of  fifteen  years'  experience  as  a 
rectal  specialist.  ...  A  careful  perusal  of  Mathews's  work  can  not  fail  to  give  the  practi- 
tioner all  the  knowledge  that  is  desirable  to  successfully  diagnosticate  and  treat  any  case  of 
rectal  disease  that  may  come  before  him,  if  he  possesses  a  modicum  of  the  dexterity  that  an 
ordinary  surgeon  should  have.  .  .  .  The  book  is  lich  in  clinical  material,  and,  in  the  writer's 
opinion,  is  the  best  work  on  this  specialty  yet  published.  The  publishers  have  done  their 
woi'k  well,  the  six  chromolithographs  being  artistic." — Chicago  Medical  Recorder. 

"...  The  work  is  a  most  practical  and  classical  presentation  of  the  vast  and  varied 
experience  of  a  painstaking  observer  and  worker.  The  specialist  will  buy  it  and  read  it, 
otherwise  he  would  not  be  progressive.  The  general  practitioners,  above  all,  should  procure 
and  read  this  book,  tor  the  reason  that  it  will  at  least  assist  them  in  making  a  correct 
diagnosis ;  and,  if  they  care  to  treat  these  diseases,  it  gives  them  all  that  is  newest  and 
best." — Medical  Mirror. 

"  This  book  we  think  is  decidedly  original  in  many  of  its  features.  The  author  has  not 
taken  other  men's  opinions  as  hi^  guide, "for  the  reason  that  in  his  fifteen  years'  experience 
as  a  rectal  specialist  he  has  learned  'that  many  things  that  arc  taught  are  not  true,  and  that 
many  true  things  have  not  been  taught.'  He  has  therefore  accepted  as  truths  only  those  things 
which  could  be  substantiated  by  facts,  and  has  here  recorded' them.  Several  chapters  new 
to  books  on  this  subject  have  been  introduced  by  him,  among  which  will  be  found  the  follow- 
ing :  Disease  in  the  Sigmoid  Flexure,  the  Hysterical  or  Nervous  Eectum,  Anatomy  of  the 
Eectum  in  Kelation  to  Uelle.xcs,  Antiseptics  in  Rectal  Surgery,  and  a  New  Operation  for  i'istula 
jnAno.  .  .  .  niustrated  with  six  excellent  colored  plates  and  numerous  cuts  ;  clearly  printed 
with  large  type,  and  nicely  bound,  it  presents  a  most  attractive  appearance.  We  do  net 
know  of  any  work  on  the  subject  which  more  thoroughly  meets  our  approval." — Memphis 
Medical  Monthly. 

D.   APPLETON   AND    COMPANY,  NEW  YORK. 


A  TEXT-BOOK  OF 

ANIMAL   PHYSIOLOGY, 

With  Inteodtjctoey  Chapters  on  General  Biology,  and 
A  Full  Treatment  of  Reproduction, 

For  Students  of  Human  and  Comparative  Medicine, 

Bt  WESLEY  MILLS,  M.  A.,  M.  D., 

PEOFESSOR  OF   PHYSIOLOGY  IN    MC  GILL   UNIVERSITY  AND    THE    VETERINARY  COLLEGE,   MONTREAL. 


8vo.    With  505  lUustrations.    Cloth,  $5.00 ;  sheep,  $6.00. 


"...  The  author  has  set  himself  a  task,  as  announced  in  the  preface,  of  trying  to 
make  the  student  an  observer  and  reasoner,  rather  than  merely  to  tax  his  memory ;  to 
acquaint  him  with  the  general  truths  in  the  broad  domain  of  bi'ology,  rather  than  to  over- 
whelm him  with  useless  detail  and  burdensome  statistics.  None  who  carefully  peruse 
his  work  can  fail  to  recognize  that  the  subject  has  been  successfully  presented  in  accord- 
ance  with  this  plan.  ,  .  .  The  general  merit  of  the  work  easily  places  it  on  a  par  with 
any  text-book  yet  written  for  beginners  in  this  branch ;  and  the  clear  deductions  of  the 
difference  in  function  and  general  structure  between  man  and  lower  animals  can  not  fail 
to  give  broader  ideas  of  the  whole  science." — Joseph  Eichberg,  M.  D.,  Professor  of 
Physiology  in  Aliami  Medical  College,  Cincinnati,  Ohio. 

"...  I  am  pleased  to  accord  this  work  my  hearty  indorsement,  simply  from  the 
fact  that  it  presents  the  subject  in  a  new  way,  and,  strange  to  say,  in  a  manner  that  we 
wonder  had  not  been  thought  of  before,  viz.,  the  comparative  animal  physiology  together 
with  biology  and  embryology,  together  with  evolution,  all  in  a  work  quite  suitable  for  a 
medical  student.  Hitherto  we  have  been  compelled  to  go  to  natural  history  for  these 
matters.  ...  It  surely  deserves  a  place  in  our  literature." — J.  0.  Stillson,  M.  D.,  Pro- 
fessor of  Physiology  in  the  Central  College  of  Physicians  and  Surgeons  of  Indianapolis,  Ind. 

"I  am  delighted  with  Dr.  Mills's  book,  the  plan  of  which  is  excellent,  and  the  details 
well  worked  out.  It  will  give  students  in  human  physiology  a  new  insight  into  the  rela- 
tions of  the  subject." — William  Osler,  M.  D.,  Professor  of  Physiology  in  Johns  Hopkins 

University. 

"...  It  fills  a  gap  in  the  works  on  physiology  hitherto  vacant,  and  I  commend  it 
cordially  as  an  excellent  work." — Egbert  Reyburn,  M.  D.,  Professor  of  Physiology  in  the 
Medical  Department  of  Howard  Utiiversity,  Washington,  D.  C. 

"  As  a  text-book  for  students  this  work  will  undoubtedly  take  a  high  place,  not  alto- 
gether because  it  is  a  succinct  and  clear  record  of  the  latest  knowledge  in  animal  physi- 
ology, but  also  on  account  of  its  being  founded  on  the  true  principles  of  teaching. 
Especial  care  is  taken  to  point  out  what  is  really  known ;  to  separate  the  known  from 
the  unknown ;  to  show  what  directions  our  investigations  must  take  in  order  that  our 
knowledge  may  increase.  The  work  is  well  printed  and  profusely  illustrated,  and  reflectB 
great  credit  on  the  publishers." — Montreal  Medical  Journal. 


D.  APPLETON   AND   COMPANY,  NEW  YORK. 


June,  1900. 

MEDICAL 

AND 

HYGIEl^IC    WOEKS 

PUBLISHED   BY 

D.  APPLETON  AND  COMPANY,  72  Fifth  Avenue,  New  York. 


ADLDE  (JOHN).  The  Pocket  Pharmacy,  with  Therapeutic  Index.  A  resume 
of  the  Chnical  AppHcations  of  Eemedies  adapted  to  the  Pocket-case,  for 
the  Treatment  of  Emergencies  and  Acute  Diseases.     12mo.     Cloth,  $2.00. 

BAILEY  (PEAROE).  Accident  and  Injury :  Their  Relations  to  Diseases  of 
the  Nervous  System.  8vo,  430  pages.  With  55  Illustrations.  Cloth, 
$5.00  ;  sheep,  $6.00.     {Sold  only  ly  subscription.) 

BARKER  (LEWELLYS  F.).  The  Nervous  System  and  its  Constituent  Neu- 
rones. Designed  for  the  Dse  of  Practitioners  of  Medicine  and  of  Students 
of  Medicine  and  Psychology.  8vo,  1122  pages.  With  Two  Colored  Plates 
and  676  Illustrations  in  the  Text.     Cloth,  $6.00. 

BARTHOLOW  (ROBERTS).  A  Treatise  on  Materia  Medica  and  Therapeutics 
Tcflth  edition.  Revised,  enlarged,  and  adapted  to  "The  New  Pharmacopoeia." 
8vo.     Cloth,  $5.00;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  A  Treatise  on  the  Practice  of  Medicine,  for  the 
Use  of  Students  and  Practitioners.  Seventli  edition,  revised  and  enlarged. 
8vo.     Cloth,  $5.00;  sheep,  $6.00. 

BARTHOLOW  (ROBERTS).  On  the  Antagonism  between  Medicines  and  be- 
tween Remedies  and  Diseases.  Being  the  Cartwright  Lectures  for  the  Year 
1880.     8vo.     Cloth,  $1.25. 

BASTIAN  (H.  CHARLTON).  Aphasia,  and  Other  Speech  Defects.  8vo,  366 
pages.     With  Illustrations.     CJoth,  $4.00. 

BASTIAN  (H.  CHARLTON).  Paralyses:  Cerebral,  Bulbar,  and  Spinal  A 
Manual  of  Diagnosis  for  Students  and  Practitioners.  With  136  Illustra- 
tions.   Small  8vo,  6Y1  pages.     Cloth,  $4.50. 

BASTIAN  (H.  CHARLTON).  Paralysis  from  Brain  Disease  in  its  Common 
Forms.     With  H lustrations.     12m o,  340  pages.     Cloth,  $1.75. 

BERKLEY  (HENRY  J.).  A  Treatise  on  Mental  Diseases.  8vo.  Illustrated. 
{In  jjvess.) 

BILLROTH  (THEODOR).  General  Surgical  Pathology  and  Therapeutics.  A 
Text-Book  for  Students  and  Physicians.  Translated  from  the  tenth  German 
edition,  by  special  permission  of  the  author,  by  Charles  E.  Hackley,  M.  D. 
Fifth  American  edition,  revised  and  enlarged.     8vo.     Cloth,  $5.00;  sheep,  $6.00. 

BOYCE  (RUBERT).  A  Text-Book  of  Morbid  Histology.  For  Students  and 
Practitioners.     With  130  Colored  Illustrations.     Cloth,  $7.50, 

BRAMWELL  (BYROM).  Diseases  of  the  Heart  and  Thoracic  Aorta.  Illus- 
trated with  226  Wood-Engravings  and  68  Lithograph  Plates,  showing  91 
Figures;  in  all,  317  Illustrations.    8vo.     Oloth,  $8.00;  sheep,  $9.00. 


BRYANT  (JOSEPH  D.).  A  Manual  of  Operative  Surgery.  TliU-d  edition,  revised 
and  enlarged.    793  Illustrations.     2  vols.,  8vo.     Cloth,  $5.00 ;  eheep,  $6.00. 

BUET  (STEPHEN  S.).  Exploration  of  the  Chest  in  Health  and  Disease.  8vo, 
210  pages.     With  Illustrations.     Cloth,  $1.50. 

CAMPBELL  (F.  R.).  The  Language  of  Medicine.  A  Manual  giving  the  Origin, 
Etymology,  Pronunciation,  and  Meaning  of  the  Technical  Terms  found  in 
Medical  Literature.     8vo.     Cloth,  $3.00. 

OAEMICHAEL  (JAMES).  Disease  in  Children.  A  Manual  for  Students  and 
Practitioners.  Illustrated  with  Thirty-one  Charts.  12mo,  591  pages. 
(Students'  Seeies.)     Cloth,  $3.00. 

OHAUVEAU  (A.).  The  Comparative  Anatomy  of  Domesticated  Animals. 
Revised  and  enlarged,  vpith  the  co-operation  of  S.  Arloing,  Director  of  the 
Lyons  Veterinary  School.  Second  English  edition.  Translated  and  edited 
by  George  Fleming,  C.  B.,  LL.  D.,  F.  R.  C.  V.  S.  8vo,  1084  pages,  with  585 
Illustrations.     Cloth,  $7.00. 

CORNING  (J.  L.).  Brain  Exhaustion,  with  some  Preliminary  Considerations 
on  Cerebral  Dynamics.     Crown  8vo.     Cloth,  $2.00. 

CORNING  (J.  L.).  Local  Anaesthesia  in  General  Medicine  and  Surgery.  Being 
the  Practical  Application  of  the  Author's  Recent  Discoveries.  With  Illus- 
trations.   Small  8vo.     Cloth,  $1.25. 

CURRIER  (ANDREW  F.).  The  Menopause.  A  Consideration  of  the  Phe- 
nomena which  occur  to  Women  at  the  Close  of  the  Child-bearing  Period, 
with  Incidental  Allusions  to  their  Relationship  to  Menstruation.  Also  a 
Particular  Consideration  of  the  Premature  (especially  the  Artificial)  Meno- 
pause.    12mo,  284  pages.     Cloth,  $2.00. 

DAVIDSON  (ANDREW).  Geographical  Pathology:  An  Inquiry  into  the 
Geographical  Distribution  of  Infective  and  Climatic  Diseases.  2  vols, 
Bvo.     Cloth,  $7.00. 

DENCH  (E.  B.).  Diseases  of  the  Ear.  A  Text-Book  for  Practitioners  and 
Students  of  Medicine.  With  8  Colored  Plates  and  152  Illustrations  in  the 
text.    Second  edition,  revised.     8vo.     Cloth,  $5.00 ;  sheep,  $6.00. 

DEXTER  (FRANKLIN).  The  Anatomy  of  the  Peritonaeum.  12mo.  With 
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DOTY  (ALVAH  H.).  A  Manual  of  Instruction  in  the  Principles  of  Prompt 
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tions for  the  Hospital  Corps,  U.  S.  A.  Designed  for  Mihtary  and  Civil  Use. 
Third  edition,  revised  and  enlarged.     121  Illustrations.    12mo.     Cloth,  $1.50.    ^ 

EVANS  (GEORGE  A.).  Hand-Book  of  Historical  and  Geographical  Phthisi- 
ology.  With  Special  Reference  to  the  Distribution  of  Consumption  in  the 
United  States.     8vo.     Cloth,  $2.00. 

EWALD  (C.  A.).  The  Diseases  of  the  Stomach.  Second  American  edition, 
translated  from  the  third  German  edition,  by  Morris  Manges,  A.M.,  M. D., 
Attending  Physician  to  the  Outdoor  Department,  Mount  Sinai  Hospital, 
New  York  City.  8vo.  With  Illustrations.  612  pages.  Cloth,  $5.00 ; 
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FLINT  (AUSTIN).  Medical  Ethics  and  Etiquette.  Commentaries  on  the 
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FLINT  (AUSTIN).  Medicine  of  the  Future.  An  Address  prepared  for  the 
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of  Dr,  Flint,-    12mo.     Cloth,  $1.00. 


FLINT  (AUSTIN,  Jr.).  Text-Book  of  Human  Physiology;  designed  for  the 
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hundred  and  sixteen  Woodcuts  and  Two  Plates.  Fourth  edJtion,  revised. 
Imperial  8vo.     Cloth,  $6.00 ;  sheep,  |7.00. 

FLINT  (AUSTIN,  Jr.).  The  Physiological  Effects  of  Severe  and  Protracted 
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tion of  Nitrogen.     12mo.     Cloth,  |1.00. 

FLINT  (AUSTIN,  Jr.).  The  Source  of  Muscular  Power.  Arguments  and  Con- 
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FLINT  (AUSTIN,  Jr.).     Physiology  of  Man.     Designed  to  represent  the  Exist- 
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Body.     Complete  in  5  vols.,  8vo.     Per  vol.,  cloth,  $4.50  ;  sheep,  $5.50. 
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FLINT  (AUSTIN,  Jr.).  Manual  of  Chemical  Examinations  of  the  Urine  in 
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Varieties  of  Urinary  Calculi.     Revised  edition.     12mo.     Cloth,  $1.00. 

FOSTER  (FRANK  P.).  Illustrated  Encyclopaedic  Medical  Dictionary  :  Being 
a  Dictionary  of  the  Technical  Terms  used  by  Writers  on  Medicine  and  the 
Collateral  Sciences  in  the  Latin,  Enghsh,  French,  and  German  Languages, 
The  work  consists  of  Four  Volumes,  and  is  sold  in  Parts;  Three  Parts  to 
a  Volume.     {Sold  only  by  subscription.) 

FOSTER  (FRANK  P.).  A  Reference-Book  of  Practical  Therapeutics,  by 
various  writers.  In  Two  Volumes.  Edited  by  Frank  P.  Foster,  M.  D., 
Editor  of  The  New  York  Medical  JournaL  Cloth,  $5.00;  sheep,  $6.00; 
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Morrow,  M.  D.     8vo.     Cloth,  $2.00;  sheep,  $3.00. 

FRIEDLANDER  (CARL).  The  Use  of  the  Microscope  in  Clinical  and  Patho- 
logical Examinations.  Second  edition,  enlarged  and  improved,  with  a 
Chromolithograph  Plate.  Translated,  with  the  permission  of  the  author, 
by  Henry  C.  Coe,  M.  D.     8vo.     Cloth,  $1.00. 

FUCHS  (ERNEST).  Text-Book  of  Ophthalmology.  With  178  Woodcuts. 
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tion. By  A.  Duane,  M.  D.  8vo.  With  numerous  Illustrations.  Cloth, 
$5.00 ;  sheep,  $6.00.     {Sold  only  by  subscription.) 

GARMANY  (JASPER  J.).  Operative  Surgery  on  the  Cadaver.  With  Two 
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Arteries  of  Arm,  Abdomen,  and  Lower  Extremity.  Small  8vo.  Cloth, 
$2.00. 

GIBSON-RUSSELL.  Physical  Diagnosis:  A  Guide  to  Methods  of  Clinical  In- 
vestigation. By  G.  A.  Gibson,  M.  D.,  and  William  Russell,  M.  D.  With 
101  Illustrations.     12mo.     (Students'  Series.)     Cloth,  $2.50. 

GOULE  Y  (JOHN  W.  S.).  Diseases  of  the  Urinary  Apparatus.  Part  I.  Phleg- 
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fVi^npjY 


